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West Virginia University Libraries 

3 0802 102296113 8 



Dr. W. Ross Batson 

Pine Grove , W. Va. 




MAR 3 , W 
MAR 10*6S 

- 1 1 BIO 






Dental Surgeon of United States Army and Pres- 
ident of Army Examining Board for Dental 

Octavo. 635 pages. 725 illustrations. 
Cloth, $5.00. Sheep, $6.00. 



Mouth Hygiene 


Mouth Sepsis 










I? K3o f 


By J. B. Lippixcott Covipasy 

Printed by J. B. Lippincott Company 
The Washington Square Press, Philadelphia, U. S.A. 


Who For More Than Forty Years Has Been My 

Chief Inspiration This Little Book Is 

Affectionately Dedicated. 


In the preparation of this little text- 
book the writer has endeavored to meet 
the needs of the Dental Profession, of 
students of dentistry and medicine, trained 
nurses, school-teachers, sanitarians, and 
the general public, for a work on the sub- 
ject of mouth hygiene and mouth sepsis 
that would be comprehensive and not 
too technical. 

All technical terms when used have 
been explained, so that the lay reader 
will be able to grasp the subject with the 
same degree of understanding as would 
the student of dentistry or medicine. 

The subject is one of such vast impor- 
tance to individual and public health, in- 
tellectual progress, and good citizenship, 
that it is hoped that the facts here gath- 
ered, and the suggestions made, will not 
only prove instructive and interesting as 



matters of reference, but may be instru- 
mental in creating greater interest and en- 
thusiasm in the subject of mouth hygiene, 
and thus save many children from lives 
of misery caused by preventable oral dis- 
eases, which, if uncorrected, may lead to 
invalidism, immorality, drunkenness, 
crime, or insanity. 





I. Introduction 1 

II. Prevalence of Oral Diseases 19 

III. The Human Mouth; Its Care From 
Birth to the Completion of First 

Dentition 34 

TV. The Human Mouth; Its Care Dur- 
ing Second Dentition 53 

V. The Human Mouth; Its Care Dur- 
ing Illness 77 

VI. Proper Mastication and Proper 

Breathing 90 

, VII. Mouth Hygiene and the School 

Curriculum 98 

VIII. Mouth Sepsis 109 

IX. Diseases of the Teeth and Mouth 

Caused by Oral Sepsis 128 

X. Diseases of the Throat, the Ear, 
the Eye, and the Cervical 
Glands Caused by Oral Sepsis . . . 139 
XI. Diseases of the Stomach, Intes- 
tines, and Other Viscera Caused 

by Oral Sepsis 162 



XII. The Psychological Effects of Den- 
tal and Oral Diseases and Sep- 
sis . . 181 

XIII. The Psychological Effects of Phy- 

sical Deformities 192 

XIV. Oral Sepsis and Reflex Dental 

Irritation as Causes of Drunk- 
enness, Neurasthenia, Melan- 
cholia, and Insanity. . 202 


XV. The Oral Hygiene Propaganda and 
the Result of Experimental 
Work 223 


no. PAQB 

I. Head of Infant, Front View, showing Pri- 
mary Dentition at arout the Seventh 

Month 40 

II. Right Side of Same 40 

III. Left Side of Same 40 

IV. Head of Child, Front View, showing Com- 

plete Primary Dentition and Secondary 
Dentition in Various Stages of Forma- 
tion 54 

V. Right Side of Same 54 

VI. Left Side of Same 54 

VII. Adult Head, showing Complete Secondary 

Dentition. (After Dr. Cryer) 58 

VIII. Calcification of Deciduous and Perma- 
nent Teeth 58 

IX. Watkins Adult and Child's Tooth-drushes 70 
X. Showing Impacted Lower Third Molar 

Dried Specimen. (After Dr. Cryer) . . 204 
XI. Impacted Cuspid, Upper Jaw. Dried Speci- 
men. (After Dr. Cryer) 204 

XII. Inverted Upper Third Molar. Living Sub- 
ject. (After Dr. Cryer) 204 







Hygiene. — Hygiene is that branch of 
sanitary science which treats of the laws 
of health and its preservation. 

Oral Hygiene. — Mouth hygiene treats 
of the health of the mouth and its 

Sanitary Science. — The science which 
includes a consideration of all that can be 
done for the prevention of disease and the 
promotion of public health. 

Sanitation, therefore, is prophylaxis, and 
prophylaxis is the prevention of disease. 

Health. — That condition of the body 
in which all its organs are performing 
their functions in a normal manner. A 
hale or whole condition of body. 

A noted monarch once said, " The 
health of the people is the supreme law/ 9 
A sentence more wise than this was never 


spoken by human lips, for the idea here 
expressed lies at the very foundation of 
all material, intellectual and spiritual 
progress of a nation; and without it no 
true national greatness can ever be 

This fact is becoming more and more 
generally recognized by all civilized na- 
tions, and much interest is being mani- 
fested by the public generally in the 
efforts that are being made to stamp out 
disease, improve the public health, and 
increase longevity. 

With this end in view great efforts 
are being made by the national govern- 
ment, by the various State governments 
and municipal boards of health along 
the lines of scientific sanitation to pro- 
tect the public and the individual from 
the detrimental effects of impure water, 
unwholesome foods and beverages; the 
poisonous emanations of decomposing 
garbage and sewerage; the harmful ef- 
fects of bad and insufficient ventilation, 
and the overcrowding of tenement houses ; 
the isolation of all persons afflicted with 
infectious and contagious diseases, and 
the fumigation of clothing worn and 


buildings occupied by such persons; the 
fumigation of all vessels upon which such 
diseases are found and the cargoes therein 

Physicians generally are teaching their 
patients the value of observing the various 
common rules of hygiene and sanitation 
and personal cleanliness; and yet the 
majority, the great majority have not 
yet learned to appreciate the fact that 
an unclean mouth is a most prolific, if 
not the most prolific, source of danger 
to the health of the individual of which we 
have any knowledge. 

Dr. Osier, in a recent address before 
the students of the Royal Dental Hospital 
of London, said, 'You have just one 
gospel to preach, and you have got to 
preach it early, and you have got to preach 
it late, in season and out of season. It. 
is the gospel of the cleanliness of the 
mouth; cleanliness of the teeth; cleanli- 
ness of the throat. These three things 
must be your text through life." 

" Oral hygiene — the hygiene of the 
mouth — there is not one single thing more 
important to the public in the whole range 
of hygiene than that; and it is with that 



which you, as practitioners, will have to 

The dentist is often thought to ex- 
aggerate the importance of a clean, 
healthful mouth and good, serviceable 
teeth; and to draw upon his imagination 
when he speaks of the great dangers to 
the general health which lie hidden in 
decayed teeth, dento-alveolar abscesses, 
pyorrhoea alveolaris, and other dental 

Upon this point Prof. Osier has also 
placed himself on record. He says, " If 
I were called upon to state which of the 
two, in my opinion, causes the most evil, 
alcohol or decayed teeth, I should un- 
hesitatingly say decayed teeth." 

Dr. Kirk, of the Dental Cosmos, says: 
" In Great Britain a systematic study 
of the mouth conditions of the public- 
school children revealed the alarming fact 
that only three or four per cent, had 
sound dentures, and that dental caries was 
an evil that was undermining the health 
of the nation. Similar studies in other 
countries furnished statistics which in 
general correspond with the figures ob- 
tained in England, showing that dental 


caries is a disease universal in its distribu- 
tion and constituting a factor of ill health 
second in importance to no other which 
affects the human race." 

Dr. D. D. Smith, in a paper, read 
before the New York Institute of 
Stomatology, upon Oral Prophylaxis, 1 
says: " It may seem presumptuous to in- 
timate that in this subject of oral prophy- 
laxis, when fully comprehended, are 
matters of a magnitude to radically 
modify the present thought and concep- 
tion of dentistry, and to greatly change 
the present methods of practice. To ad- 
vance a step farther, and suggest that 
there are hidden away under the debris 
of the oral cavity secrets of greater im- 
portance to the comfort and welfare of 
civilization than the great discovery of 
vaccination by Jenner in 1796, will doubt- 
less seem as a magnification verging upon 
absurdity. And yet we venture to pre- 
dict that the future of dentistry will 
disclose this as a truism." 

Dr. L. Ashley Faught, 2 in speaking 

1 International Dental Journal, vol. xxii, p. 817, 1901. 

2 Dental Cosmos, vol. xliv, p. 1021, 1902. 



of Oral Hygiene, says: " It has come to 
be more appreciated that one of the great 
causes of decay in the teeth is lack of 
cleanliness, and that decay begins at the 
outer surface of the tooth, most frequently 
at the points most difficult to keep 
clean. . . . Clearly the work of the 
patient is oral hygiene, — the maintaining 
of the oral cavity in a state of health. 
The work of the dentist is dental prophy- 
laxis, — the placing of the teeth in condi- 
tion to prevent disease, a state favorable 
to oral hygiene. Thus it appears, from 
any strict definition of the two words, 
that the end to be obtained by either 
dentist or patient is one and the same, 
— prevention of disease, maintenance of 

In an article on Oral Hygiene read by 
Dr. L. P. Bethel, 3 he quotes Dr. Knowl- 
ton, dental examiner at the Barberton, 
Ohio, Diamond-match Factory, as say- 
ing: " He is confident that the influence 
of oral hygiene is farther reaching than 
ordinarily imagined. Since its enforce- 
ment among these employees it has been 

s Fourth International Dental Congress, St. Louis, 1904. 


a noticeable fact that fewer days are lost 
through sickness. He believes it has an 
influence on the digestive tract and that 
better general health is maintained. Also 
it has been noticed that during epi- 
demics of disease fewer employees are 
affected by prevailing maladies than be- 
fore these prophylactic measures were 


We know of nothing that is more 
shocking and disgusting than a mouth 
which is a stranger to the tooth-brush, 
or one that only semi-occasionally is 
treated to a half-hearted scrubbing with 
this most invaluable toilet article. Do 
we not turn away from such individuals 
with positive loathing? Do we not shun 
them almost as much as we would an 
individual suffering from small-pox? 
And why? Because they are poisoning 
the air which you and I must breathe 
with myriads of disease-producing micro- 
organisms, perhaps the organisms of pul- 
monary tuberculosis, pneumonia, diph- 
theria, tonsillitis, bronchitis, la grippe, 
and numerous others. 


The science of bacteriology applied to 
the study of the organisms found in the 
human mouth has demonstrated more 
than a hundred different forms, many of 
them disease-producing organisms. In 
fact nearly every form of pathogenic 
micro-organisms known to bacteriologic 
science has been found at some time to in- 
habit the human mouth. This being the 
fact, what an ever-present danger to the 
individual and the public is an unclean, 
unsanitary, unhygienic mouth! 

In this connection it may be well to 
consider for a few moments the rapidity 
with which some of the disease-producing 
micro-organisms reproduce themselves. 


The process of reproduction in bacteria 
is a very rapid one. Fliigge observed the 
process of segmentation in a coccus — 
a globular organism — to be completed in 
twenty minutes. Cohn has made the cal- 
culation that if it should take one hour 
to complete this process of segmenta- 

4 Marshall's Operative Dentistry, third edition, pp. 
91, 92. 



tion — division — and of the new cell to 
attain the size of the parent cell, one 
coccus, multiplying by this process, would 
in a single day produce 16,000,000 
progeny; at the end of two days 281,000, 
000,000; while at the end of the third day 
it would have reached the enormous num- 
ber 46,000,000,000,000. Such figures are 
at first thought very startling, and if the 
multiplication could go on unhindered the 
earth might soon be dominated by these 
micro-organisms. There are, however, 
many curcumstances which constantly 
oppose them; one of the chief of these is 
their own delicate susceptibility to change 
of environment, the slightest difference in 
soil, amount of oxygen, temperature, or 
moisture being sufficient in many in- 
stances to arrest their growth or com- 
pletely destroy them. Various specimens 
are found growing together, but the 
struggle for existence, and natural selec- 
tion, is as active here as elsewhere; the 
stronger and more vigorous soon destroy 
the weaker. When they enter healthy 
bodies they are attacked by the phago- 
cytes — the white cells of the blood — and 
destroyed, or they do not find a congenial 


soil in which to grow, and either die or 
are swept out of the body by the ex- 
cretory organs. 

Miller 5 has made the estimate that in 
a certain very unclean mouth there were 
not less than 1,140,000,000 micro-organ- 
isms. IThink of the vitiating effect of 
such a mouth upon the general health 
of the individual and upon the atmosphere 
of a room inhabited by such a person; of 
the myriads of these organisms that en- 
ter the lungs at every inspiration and of 
the myriads that are thrown into the 
atmosphere by every expiration and by 
every act of coughing or sneezing; of the 
multitudes that are swallowed with every 
mouthful of food or drink ; of their effect 
upon the delicate lining membrane of the 
bronchi and air-vescicles of the lungs, and 
upon the mucous membrane of the 
stomach and intestines. The wonder is 
that diseases of the throat, of the air- 
passages, of the lungs, and of the stomach 
and intestinal tract are not more common 
than they are. 

The unclean mouth is always a dis~ 

6 Micro-organisms of the Human Mouth. 


eased mouth. It has been said, " The 
man with the healthy mouth is never sick: 
the sick man never has a healthy mouth." 
The first part of this proposition may be 
open to question, but the latter never. A 
man with a healthy mouth may eat food 
or drink water or milk infected with the 
cholera bacillus or the typhoid bacillus, 
and die from their effects, in the former 
case in a few hours, in the latter in a few 
days or two or three weeks. 

As a general proposition, however, the 
statement is correct, for the man with 
the healthy mouth is usually in vigorous 
health and will be able to resist these in- 
fections if the organisms are not intro- 
duced in overwhelming numbers. If his 
opsonic index is high, which is another 
way of saying, if his resistance power is 
high, he may escape altogether. The man, 
however, who has an unclean and diseased 
mouth has never a high resistance power 
against disease. " Cleanliness is next to 
godliness," and godliness is to be Godlike. 
Can any one conceive of our God being 
unclean? Therefore, if we are Godlike 
we must be clean physically, morally, and 
spiritually. If we are Godlike we will 


be every whit clean physically as well as 
in other respects, and if we are every 
whit clean we will have clean mouths and 
keep them so. 

The tooth-brush is the yard-stick by 
which the degree of civilization of a people 
or a nation may be measured. From time 
immemorial the care which a people or a 
nation has given to its teeth, is the index 
of the degree of its civilization. 

Booker Washington, of Tuskegee, has 
said, " The tooth-brush is the greatest of 
all civilizing agents." He found that 
when he had succeeded in teaching his 
students to keep their teeth clean, he had 
stimulated in them a sense of self-respect, 
and this is necessary to civilization in its 
higher forms. 

This is to be the age of the tooth-brush, 
and the gospel of the tooth-brush is to 
be preached from one end of the world 
to the other, and nothing shall stop it, 
for it is a righteous gospel and one that 
has for its aim the betterment of the 
health and consequently of the happiness 
of the human race. 

Hygiene of the mouth must deal, not 
only with the question of cleanliness, but 


also with diseased conditions and their 
prevention. An unclean mouth leads to 
decay of the teeth, and decay of the teeth 
leads to exposure of pulps — miscalled 
nerves — which causes most excruciating 
pain. This condition if neglected leads 
to dento-alveolar abscess — miscalled ul- 
cerated teeth — which not only causes 
severe pain and great swelling when the 
abscess is an acute one, but it may lead 
to acute septicemia — blood-poisoning — 
and not infrequently to death. Or if the 
abscess pass into the chronic stage it may 
give rise to pyaemia — a chronic state of 
blood-poisoning — which may continue for 
months and finally end in death unless 
the cause is discovered and removed. 
Another diseased condition frequently 
found in the unclean mouth is gingivitis — 
inflammation of the gums — usually caused 
by the accumulation of salivary calculus — 
tartar — and the accumulations of food 
debris — particles of food left upon and 
between the teeth, which are soon in a 
state of acid fermentation from the action 
of certain bacteria always found in the 
human mouth, and which in a few hours 
forms acids which dissolve the lime salts 



in the enamel and dentine and thus estab- 
lish dental decay; while the accumula- 
tion of the tartar and the food debris act 
as mechanical and chemical irritants to the 
gum tissue and thus establish inflamma- 
tion of the gums. 

This condition of inflammation of the 
gums frequently leads to atrophy — a 
wasting away of tissue — and to a loss of 
the alveolus — bony socket of the tooth — 
by a process of caries — an inflammatory 
condition which dissolves the bone by slow 
degrees — and ends in the final loss of the 

Another disease that is frequently 
found in an unclean mouth is pyorrhoea 
alveolaris, or Riggs's disease — a chronic 
inflammation located in the pericemen- 
tum — membrane covering the roots of the 
teeth — and in the alveolar process or sock- 
ets of the teeth, which produces a gradual 
and painful dissolution of these structures 
accompanied by a flow of pus from fhe 
alveolus or socket, resulting in an ulti- 
mate loss of the teeth, and due to con- 
stitutional causes, such as rheumatism, 
gout, diabetes, and Bright's disease, and 
aggravated by local irritation from 



salivary deposits — tartar — and the accu- 
mulation upon and around the teeth of 
food debris which is in a septic or putrefy- 
ing condition. 

Stomatitis — inflammation of the lining 
mucous membrane of the mouth — in its 
various forms is frequently present in an 
unclean mouth. This disease is most often 
found in the mouths of infants and little 
children, particularly in foundling hospi- 
tals and orphan asylums. It is an infec- 
tious disease and readily transmitted by 
nursing-bottles, spoons, and drinking- 
cups. The disease is mycotic — fungus 
micro-organisms — in its origin ; the organ- 
isms flourishing in unclean rubber nipples, 
nursing-bottles, rubber soothers or com- 
forts, milk-bottles, and unsanitary re- 
frigerators, etc. 

Pharyngitis — inflammation of the back 
part of the throat — is another common 
disease often found associated with an 
unclean mouth, and is due usually to in- 
fection from the mouth. 

Tonsillitis — inflammation of the glands 
lying upon either side of the inner surface 
of the throat — is usually found associated 
with an unclean mouth. It is an infec- 



tious disease, and is also due to micro- 
organisms. This disease spreads very 
rapidly among school-children housed in 
close and ill-ventilated school-rooms and 
who are permitted to use common drink- 
ing-cups, the common slate, pencils, and 
pens. The public drinking-cup, the com- 
mon slate, pencils, and pens should be 
banished forever from our public schools 
as an imperative sanitary measure against 
the spread of such infectious and con- 
tagious diseases. 

During the hot season of the year city 
people who can afford to do so flee to the 
country with their children, to find cool, 
pure air and fresh food, and this is wise 
and beneficial, provided the sanitary con- 
ditions of the new environment are what 
they should be. Many of these summer 
resorts are far from being what they 
should be, from a sanitary stand-point. 
The ignorance or the cupidity of the 
management of many of these places is 
such that they make no adequate pro- 
vision for tlie protection of the water 
supply from contamination with the 
sewerage of the premises, and, instead of 
burning all kitchen refuse, cart it into 



some back lot and allow it to rot and 
putrefy in the sun and breed flies by the 
million. Such places are more dangerous 
to the health and lives of the children 
than the heat and possible unsanitary con- 
ditions from which they have fled. 

Flies are a prolific source of infection. 
They are the most filthy of all insects, 
and every effort should be made to pre- 
vent their propagation and multiplication 
by destroying all matter upon which they 
feed. Refuse from the kitchen, garbage, 
excreta of the body, stable droppings, and 
refuse should be removed each day and 
destroyed by burning. All food and 
nursery apparatus should be protected 
from flies by proper cover-screens. Most 
of the sporadic cases of typhoid fever 
found in our cities can usually be traced 
to an infection received at some supposed 
health resort or summer camp. 

Most people are extremely careful to 
have the foods and drink which enter their 
mouths free from everything that could 
be considered in any way unsanitary ; and 
yet many of these same people have very 
unclean mouths, not seeming to recognize 
the fact that they carry within their 
2 1; 


mouths unsanitary conditions that are 
infinitely more dangerous to health and 
life than the dirt and possibly infectious 
materials that have been removed in the 
careful preparation of their food, and 
which, when thoroughly masticated in an 
unclean, unsanitary mouth, has been ren- 
dered positively unfit to enter the stomach. 
Is this failure to recognize the importance 
of a clean mouth due to ignorance, in- 
difference, or inconsistency? We think 
we may safely say, in deference to the 
usual habits of the people generally, that 
it is due to ignorance of the facts. With 
this thought in mind it will be our en- 
deavor to lay these facts, as best we may, 
before our readers in the following pages. 




Diseases of the mouth are so prevalent 
that it may be said practically no one 
escapes. The writer during a practice, 
both civil and military, of more than forty 
years, in which he has examined many 
thousands of mouths, has never met with 
but four instances of persons who had 
reached adult life who were free from 
any form of dental or oral disease. One 
was a young lady twenty-four years of 
age, another a gentleman of fifty, the 
third an officer in the United States 
Army, twenty-four years old, a recent 
graduate of West Point, and the fourth 
a lady, a college graduate, twenty-five 
years of age. 

Dental caries — dental decay — is with- 
out doubt the most common disease that 
affects the human family at the present 
time, and from which very few persons 



among civilized nations wholly escape. It 
seems to be pre-eminently a disease of 
higher civilization, as it is most common 
among those nations which are recognized 
as having the highest civilization ; and yet 
no race or tribe of men yet discovered, 
whether savage, barbarous, semi-civilized, 
or civilized, ancient or modern, has ever 
wholly escaped it. Archaeology, history, 
and anthropology all prove the correctness 
of this statement. Evidences are not lack- 
ing that the prehistoric man suffered from 
dental decay, alveolar abscesses, — mis- 
called ulcerated teeth — and other dental 
diseases. Many of the Egyptian mum- 
mies found in our great museums, and 
skulls of prehistoric periods, show well- 
marked evidences of caries and other den- 
tal diseases. One Egyptian mummy in the 
British Museum, dating back to a period 
about 2800 B. C, or more than four 
thousand seven hundred years ago, shows 
undisputed evidences of dental caries and 
other dental lesions. 

The collections of crania of the pre- 
historic inhabitants of North and South 
America in the National Museum in 
Washington show occasional evidences of 



dental caries and numerous evidences of 
alveolar abscess, from death of the tooth- 
pulp caused by the wearing down of the 
teeth. Evidences of pyorrhoea alveolaris 
are very rare. Dental anomalies, particu- 
larly irregularities in position, inverted 
teeth, and supernumerary teeth, are quite 

It would be interesting to pursue this 
subject at greater length did space in this 
little volume permit. 


Very little interest has been manifested 
by the profession in the gathering of re- 
liable statistics upon this subject until 
quite recently. The first comprehensive 
and reliable work of this kind was per- 
formed by the School Committee of the 
British Dental Association (Tomes). 
They reported having examined the 
mouths of 3368 boys and girls at the Han- 
well and Sutton schools and at the Ex- 
mouth training-ship. Out of this number 
only twenty-three per cent, had sound 
dentures, or, in other words, seventy- 
seven per cent, were affected with dental 


decay. These boys and girls ranged from 
three and a half to seventeen years of age, 
but the majority were from five to four- 
teen. Two hundred and five children 
belonging to high-class schools did not 
compare favorably with those less fortu- 
nately placed. Further comparison was 
not made, as the number was too small 
to give conclusive results. 

Major P. J. Probyn, of the medical 
service of the British Army, says : 1 

" On comparing the various recruiting 
returns in the Army Medical Department 
reports, we find that an immense amount 
of good material is lost to the service 
from defective teeth, either due to cario- 
necrosis — dental decay — or the actual loss 
of the members; and this, be it noted, 
occurs in otherwise strong and healthy 
youths, who, if fitted with artificial den- 
tures, may still become useful fighting 
men. At one time the Government would 
not allow the enlistment of men with de- 
fective teeth, and not without a certain 
good reason, for what use is a man in 
the field with defective teeth? He will 

British Journal of Dental Science, vol. li, p. 873, 1908. 



soon lose his good state of health if he is 
not able to thoroughly masticate the hard 
biscuit and ' bully ' beef. Now I am glad 
to say a much more liberal view is taken 
of the situation, and recruiting officers 
are not hampered, but must use their own 
discretion and may admit men with 
artificial dentures. 

" In the last report of the Army Medi- 
cal Department (1907) we find that 19 
per cent, of the candidates were lost to 
the army on account of defective teeth." 

Ottofy computed, from an examination 
of 14,644 teeth of American public-school 
children, that dental caries was present 
in 27.33 per cent, in the boys and 32.67 
per cent, in the girls. 

This statement gives a better showing 
for the American public-school children 
than for the children in the Hanwell and 
Sutton charity schools. This difference 
is explained by the fact that the latter 
children were from the poorest class of 
English society, while the American 
public school represents all classes of 
society, including many who receive regu- 
lar attention from the family dentist. 

The Schleswig-Holstein Dental Soci- 



ety, 2 in a recent examination of the 
mouths of the school-children in Northern 
Germany, conducted by Dr. Greve of 
Lubeck, reports that of 19,725 children 
examined, 95 per cent, showed dental 
caries. This investigation included the 
children of nineteen towns. The boys 
were found to have somewhat better teeth 
than the girls, the difference being about 
3 per cent, in favor of the boys. 

From the dental inspection of the public 
schools of the city of Antwerp in 1900 6 
the following facts were obtained: " The 
number of attendants of the schools in 
March were — boys 9543; girls 10,148; 
kindergarten 4778; total 24,469. The 
kindergartens are frequented by children 
of three to six years of age; in the other 
schools the ages vary between six and six- 
teen years. Amongst 12,000 children ex- 
amined by Dr. Verhuysen, he found 1721 
without caries, 2138 with one or two teeth 
affected, and 8141 with several teeth 
affected. During the first inspection 947 
extractions were made, in the second 545, 

2 Cor. Blatt fiir Zahn., July, 1899. 

3 Transactions American Public Health Assn., vol. xxvii, 



and in the third 405, making a total of 
1897." Associated with the decay of the 
teeth were numerous other abnormal con- 
ditions, such as inflammation of the maxil- 
lary sinus, facial phlebitis, necrosis, noma, 
ranula, and epulis. 

" The statistics lately compiled of 
children of six to fourteen years of age 
and youths from twenty to twenty-three 
years of age in Germany by the recom- 
mendation of Rose are no less lamentable. 
The best localities showed 78 per cent, of 
the people with diseased, teeth, and in 
places where calcium was scarce (?) the 
percentage reached 99." 4 Statistics from 
Sweden and Russia show similar con- 
ditions. Cunningham found that in 
10,517 pupils of the age of twelve in 
English and Scotch schools 85.8 per 
cent, had dental decay. 

In more recent examinations made of 
the school-children in various cities 
scattered all over the United States from 
north to south, from east to west, it has 
been found that dental and oral diseases 

4 E. Jessen (of Strassburg), Trans. American Pub. 
Health Assn., 1901. 



afflict from 75 to 96.5 per cent, of all the 
children examined. 

It will be observed by the preceding 
brief summary of the prevalence of dental 
and oral diseases, 5 that the nations of 
the present day which suffer most from 
these affections are the Anglo-Saxons of 
America and Great Britain, and the great 
European nations. The growth of 
modern dental science and the perfection 
of the art among these nations has been 
a work of necessity, and one which from 
its surgical and prosthetic aspects has kept 
pace in its development with the demands 
made upon it. 

But viewed from the more important 
aspect of prophylaxis, it has not yet 
attained nor kept pace with the ever- 
increasing needs in this direction. 

When one stops to consider how wide- 
spread and universal dental and oral 
diseases have become, and the increasing 
number of teeth that are destroyed by 
disease every year, we are appalled by 
the problem, and wonder if the human 
race is not destined to become edentu- 
lous — toothless. 

6 Marshall's Operative Dentistry, third edition, p. 130. 


The teeth of the present generation 
seem to be inferior to those of their im- 
mediate ancestors, while the children of 
to-day have, as a rule, a greater pre- 
disposition to dental diseases than their 
parents. In other words, there seems to 
be a gradual deterioration in the struct- 
ural development — perfection of develop- 
ment — of the teeth, and a lowering of 
the resistive powers or the vital energy 
of the system against the encroachment 
of disease. 

Perfection in the structural develop- 
ment of the teeth of city-bred children 
of the middle and better classes of 
society is the exception, defective teeth 
the rule. Little children between the 
ages of three and six years are 
frequent sufferers from dental caries, 
odontalgia, and alveolar abscess, while 
very many have defective first permanent 
molars which require operative treatment 
as soon as they are erupted. 

This is the age of steam and electricity, 
of the lightning express train, the ocean 
greyhound, of the electric telegraph and 
the telephone, the high-speed automobile 
and the flying-machine. Men and women 



too have seemingly partaken of the 
energy and speed of these forces. It is 
an age of rush and whirl. Men and 
women vie with each other and with their 
sex for place and power. In business 
and social life, in educational matters, in 
pleasures and vices, they go at high- 
pressure speed, and as a result often 
break down at a period of life when under 
more favorable circumstances they would 
still be in their prime. 

These conditions are manifested every- 
where in the civilized world, but most 
noticeably in the great cities, where the 
intensity of the struggle of the poor for 
existence, and of the well-to-do and rich 
for supremacy over their fellows in 
business, social pleasures, education, and 
display, are the greatest. Children born 
under such circumstances have generally 
constitutions which are far from robust, 
nor equal to those inherited by their 
parents, and as a consequence they are 
handicapped in their struggle for exist- 
ence either by the direct inheritance of 
disease, or of tendencies and predisposi- 
tions to disease which are the result many 
times of the terrible deprivations of 



poverty, of overwork, or of over-in- 
dulgence in the luxuries and the pleasures 
of life, or possibly of the indiscretions or 
the vices of their parents or earlier 
progenitors, — for " the sins of the fathers 
are visited upon the children, unto the 
third and fourth generations/' 

The report of the Surgeon-General of 
the U. S. Army for 1903 shows that the 
percentage of dental diseases among the 
troops serving in the United States was 
42.85. For those serving in the Philip- 
pine Islands it was 61.12, or 18.27 per 
cent, higher than for troops serving in 
the United States, while for those who 
served in Cuba and Porto Rico it was 
64.02, or 21.17 per cent, higher than for 
those who served in the United States. 

During the years 1901, 1902, 1903 the 
dental surgeons of the United States 
Army treated 70,259 teeth by filling or 
extraction. Of this number 43,704 were 
in the upper jaw and 26,555 in the lower. 
The percentage of caries for the upper 
was 62.20, while in the lower teeth it was 
37.80. The difference in liability to 
caries between the right and left sides is 
very slight, the left side being a little 



more susceptible. The number of teeth 
treated upon the right side was 35,000 
and on the left side 35,259, the percent- 
age for the right side being 49.81 and 
for the left 50.19, a difference of only 

In 1904 the writer, for the purpose of 
obtaining exact data as to the condition 
of the teeth of the United States soldiers 
under the most favorable conditions, 
selected for this purpose two regiments 
that had recently returned from the 
Philippine Islands after the service of 
two years or more. These examinations 
were conducted in the most careful and 
systematic manner by the writer and two 
junior dental surgeons as assistants, with 
the following results. In the first regi- 
ment it was found that 89.17 per cent, 
of the enlisted men were in need of im- 
mediate dental treatment; while the ex- 
amination of the second regiment revealed 
the fact that 97.25 per cent, of this com- 
mand were in a like condition. Of the 
number in both regiments who did not 
require dental treatment, several had 
been fortunate enough to receive treat- 
ment by the army dental surgeons just 



before sailing for the United States. 
The condition found in these two regi- 
ments, it is believed, is a fair sample of 
the conditions to be found in all United 
States troops who have served in the 
tropics for two or more years. 

The military reports of the armies of 
Great Britain and Europe in which den- 
tal examinations have been made show a 
similar condition in relation to the pre- 
valence of dental diseases. Some of these 
nations have already appointed dental 
surgeons to care for the teeth of their 
soldiers, while others have the matter 
under consideration. The German Army 
has taken the lead in the matter of oral 
hygiene. Orders were issued some time 
ago that every soldier should brush his 
teeth at least once each day, before 
morning inspection, and it was made the 
duty of the first sergeant of each company 
to see to it that this order was strictly 

In the Philippine Division of the 
United States Army the authorities have 
gone a step farther, by the issue of an 
order, upon the recommendation of the 
writer about three years ago, not only 



requiring the enlisted men to brush their 
teeth every day, but making it the duty 
of the post surgeon at the monthly 
special inspection to see that the men 
were keeping their teeth clean, and to 
order such as had decayed teeth to report 
to the dental surgeon for treatment. 

Through representations made to the 
Surgeon-General by the writer in 1904, 
the dental requirement for enlistment was 
raised from two serviceable opposing 
molars in each jaw — one above and one 
below — on each side, to four serviceable 
opposing molars in each jaw — two above 
and two below — on each side. The en- 
forcement of this requirement, however, 
so reduced the number of eligible recruits 
that the War Department was obliged 
to return to the original requirement of 
two serviceable opposing molars in each 
jaw — one above and one below — classing 
the bicuspids as molars. The experience 
of the writer at the Columbus Barracks 
Recruit Depot leads him to the opinion 
that there are very few young men among 
the class who apply for enlistment that 
have reached the age of twenty years who 
have not lost the first permanent molars, 



or in which these teeth are not badly de- 
cayed; while many others have lost from 
one to two bicuspids. 

From twenty-five to thirty per cent, 
of all the recruits passed by the surgeons 
at this post were ordered to report to 
the dental surgeons as needing immediate 
treatment for dental caries, — pulpitis, 
dento-alveolar abscess, salivary calculus, 
gingivitis, or necrosed teeth and roots. 

In personal conversations with volun- 
teer officers who served in Cuba and the 
Philippine Islands during the Spanish- 
American War, it was learned that from 
ten to twelve per cent, of the enlisted 
force of their several commands were 
constantly incapacitated for duty by 
reason of dental diseases. 

The introduction of dental service as 
a part of the medical care of the army 
has greatly reduced this percentage, and 
by that much has added to the health, 
comfort, and efficiency of the army. 

Great Britain, during its Boer War, 
had a similar experience, and was obliged 
to send out a number of dental surgeons 
to combat these diseases. 






The Oral Cavity, or mouth, is the 
entrance to the alimentary canal. It is 
a grinding and mixing organism, — to 
change the form of expression, a mill in 
which the food intended for the nourish- 
ment of our bodies is ground, triturated, 
and mixed with the fluids from the 
salivary glands and prepared to be acted 
upon by the gastric juices. 

This cavity is formed by the lips, 
cheeks, tongue, hard and soft palate, and 
the jaws. Emptying into this cavity by 
appropriate ducts are three series of 
salivary glands, known as the parotid, 
submaxillary, and sublingual. These 
glands secrete fluids which contain chemi- 
cal substances, elaborated by the vital 
processes of the body, ptyalin, a special 
ferment, being the most important, as 
it converts starch to sugar and prepares 
it to be acted upon by the secretions of 
the stomach, 



Situated in the surface of the mucous 
membrane of the lips, cheeks, palate, and 
tongue are numerous small glands for 
the secretion of a fluid more or less glairy 
in consistence, known as mucus. At the 
back of the mouth and at the entrance 
of the throat are situated two almond- 
shaped glands, one on either side, known 
as the tonsils. The principal known func- 
tion of these glands is to secrete a thick 
glairy mucus, which envelops each bolus 
or mouthful of food when ready to be 
swallowed, and thereby assists its passage 
from the mouth to the stomach. 

The mouth of the infant when first 
born is usually devoid of teeth. Cases 
are on record, however, in considerable 
numbers in which infants were born with 
from one to several teeth. 1 It has been 
stated that Richard Cceur de Lion of 
England and Louis XIV of France were 
born each with several teeth. Haller, in 
his " Elements of Physiology," mentions 
nineteen cases of children that were born 
with one or more teeth. The writer has 
several times been called upon to remove 

1 Marshall's Operative Dentistry, third edition, pp. 



teeth from the mouth of the new-born in- 
fant because the teeth interfered with 
nursing, and there are few physicians or 
dentists of twenty to twenty-five years' 
practice who have not had a like experi- 
ence. Dr. Crump, several years ago, re- 
ported to the Virginia Society of Dentists 
a case of a child that was born with a 
full set of deciduous or milk teeth. 

The normal activity of the salivary 
glands does not become established until 
the process of eruption of the teeth — 
cutting of the teeth — begins. Up to this 
time the diet of the infant has been com- 
posed only of milk, or ought so to be, 
and there has been no occasion for the 
presence of saliva containing the special 
ferment, ptyalin. Upon the appearance 
of the teeth the child craves, and should 
have, a more solid diet, which its alimen- 
tary system is gradually being prepared 
to receive and digest. No more repre- 
hensible practice can be indulged in by 
young mothers and nurses than that of 
feeding infants with materials that are so 
manifestly unfit as starchy foods, fruits 
and meats before the function of the sali- 
vary glands is established and a sufficient 
number of teeth have erupted to make 



mastication possible. More children die 
from improper feeding than from all other 
causes combined. 


The eruption or cutting of the decidu- 
ous or milk teeth is a physiologic process, 
and in a normal child is productive of so 
little general or local disturbance that 
many times the teeth make their appear- 
ance within the mouth before the parent 
or the nurse has realized the fact that the 
process of "teething" has really begun; 
while, upon the other hand, in children 
with impaired health and low vitality it 
often plays a prominent part in exciting 
various morbid conditions of the digestive, 
nervous, respiratory, and dermal (skin) 
systems. The subject becomes, therefore, 
one of considerable interest to the medical 
attendant and the dental specialist and of 
serious anxiety to the parents. 

There is no doubt in the mind of the 
writer that the dangers from dentition 
have been greatly exaggerated by some 
authorities, and that parents are often 
unnecessarily anxious for their offspring 
during this period; yet it must be borne 
in mind that in certain temperaments and 



under various physical conditions and en- 
vironment there is a real danger present, 
and that morbid phenomena are some- 
times excited which may progress to a 
fatal termination. When dentition is slow 
and the gums swollen and painful, lancing 
may be necessary, but this should be de- 
termined by the physician or dental 

According to the mortality tables of 
London, as cited by West, dentition was 
assigned as the cause of death of 4.8 per 
cent, of all children dying under one year 
of age, and 7.3 per cent, of those who died 
between the ages of one and three years. 
This is not a high mortality, and yet it is 
more than likely that a goodly number of 
these deaths were due to improper feed- 
ing and unclean mouth conditions, rather 
than dental irritation. 

The dangers surrounding the period of 
first dentition are much greater in large 
cities and in overcrowded localities, par- 
ticularly among the middle and lower 
classes of society, than in the suburban 
and country districts. But the greatest 
mortality is in the foundling hospitals and 
in overcrowded and filthy tenements. A 
considerable number of these cases are 



without doubt due to the unsanitary and 
unhygienic surroundings of these children 
and to unfit and spoiled food upon which 
they have been fed. 

Contemporaneously with the eruption 
of the teeth, there is a very important 
developmental process taking place in the 
follicular or glandular apparatus of the 
whole alimentary canal, in preparation 
for the necessary change soon to take 
place in the character of the food that the 
system will demand. 

This is a physiologic process, and under 
normal conditions, when all the functions 
of the body are nicely balanced, pro- 
gresses without the least disturbance of 
general health; but under opposite con- 
ditions it may be productive of serious 
gastric and intestinal complications, the 
causes of which — viz., an unclean mouth, 
improper or spoiled food, etc. — are often 
overlooked, and the disturbances w r hich 
are the result of these indiscretions during 
the period that these important physio- 
logic changes are taking place, are 
attributed to morbid dentition. 

The nervous system of the child at this 
period is also very impressible, the cerebro- 
spinal apparatus predominating to such 



an extent that slight irritations of almost 
any character, in children of certain tem- 
peraments, may be followed by more or 
less general systemic disturbances, with 
elevation of temperature, vomiting, diar- 
rhoea, bronchitis, and other catarrhal con- 
ditions, or reflex nervous phenomena, 
like strabismus, — squinting or cross-eye, — 
twitching of the facial muscles, rolling 
of the eyes, convulsions, or meningitis, — 
inflammation of the brain. 

Normal Primary Dentition — cutting 
of the milk teeth — begins between the 
fifth and eighth months after birth, and 
terminates between the twenty-fourth and 
thirty-second months. The following 
table represents the average period of the 
eruption — cutting — of the various classes 
of teeth which constitute the temporary 
denture : 

The central incisors, fron 5 to 8 months 

after birth. 
The lateral incisors, from 7 to 10 

months after birth. 
The first molars, from 12 to 16 months 

after birth. 
The cuspids (eye-teeth), from 14 to 20 

months after birth. 
The second molars, from 20 to 32 

months after birth. 

Fig. 1 

Head of Infant, Front View, showing Primary Dentition at about 
the Seventh Month. 

Fig. II. 

Right Side of Same 

Fig. Hi- 

Left Side of Same. 


The lower teeth usually appear a few 
weeks in advance of the upper ones (Figs. 
I, II, III) . 2 No general rule can be for- 
mulated from which, however, there will 
not be marked and frequent deviations. 

The variations are so marked in the 
dates of the eruption of the teeth that no 
two authors give them exactly alike. 
Tubercular and syphilitic children cut 
their teeth very early, while in rhachitic — 
rickety — children the process begins very 


As soon as a child begins to take food 
its mouth should receive attention; but 
how few mothers or nurses ever think to 
cleanse a nursing baby's mouth! Much 
if not all of the suffering that some babies 
have to endure from nursing sore 
mouth — stomatitis — might be avoided by 
a little care upon the part of the mother 
or nurse in cleansing the mouth of the 
baby after feeding. 

Oral hygiene, or oral health, must be 
based upon prophylaxis — the prevention 

' Photographs from the collection in the Library and 
Museum of the Surgeon-General, U. S. Army. 



of disease. The old, oft-repeated, and 
threadbare adage, " An ounce of preven- 
tion is worth a pound of cure," is most 
eminently applicable to the diseases of the 
mouth. A clean mouth is always a 
healthy mouth ; while an unclean mouth is 
always an unhealthy or diseased mouth. 
The mucous membrane of the mouth 
of the infant is very tender and sensitive 
and often the seat of various superficial 
lesions, consequently in cleaning the 
mouth of the infant care must be exer- 
cised not to injure or in any way abrade 
its surface. The gums of the nursing 
infant are often studded with so-called 
epithelial pearls which are in reality tiny 
retention cysts. These cysts may dis- 
appear by resorption or rupture sponta- 
neously, and usually heal without marked 
symptoms. These minute lesions, how- 
ever, may become infected from the pres- 
ence of disease-producing micro-organ- 
isms growing in the mouth, resulting in 
ulcerated patches of more or less extent, 
which are sore and painful and frequently 
prevent the child from nursing, and in 
serious cases lead to grave forms of disease 
and to sepsis. 



Moss and Epstein 3 are of the opinion 
that " the toothless mouth of the infant 
needs no especial care." From this 
opinion the writer most vigorously dis- 
sents. The uncared-for mouth of the 
nursing child is never free from particles 
of coagulated and fermenting milk, which 
are the soil upon which many forms of 
harmful micro-organisms grow and flour- 
ish. These organisms may and do often 
attack the minute lesions above referred 
to and thus establish a follicular stomati- 
tis. It stands to reason, therefore, that, 
if the cause can be excluded by keeping 
the mouth clean, the disease will be pre- 
vented. Nearly all the forms of stomati- 
tis that affect infants and small children 
may be traced to an unclean condition of 
the mouth. This being the fact, no ar- 
gument is needed to establish the relation- 
ship between cause and effect. 

Stomatitis of Nursing Children. — 
This is an affection that is rarely seen 
in children that are fed from the breast, 
unless the mother or wet nurse is unclean 
and careless about bathing the breasts 

3 Diseases of Children, vol. iii, p. 4, 1908. 


and nipples. As a rule, it is a disease 
of bottle-fed children, and is usually due 
to an unclean, unsanitary condition of the 
feeding apparatus or to spoiled or in- 
fected milk. It is a mycotic — germ — dis- 
ease, and is therefore easily prevented by 
thoroughly boiling all feeding appara- 
tus — bottles, tubes, nipples, cups, spoons, 
pans, or whatever utensils are used in 
preparing the food. The milk should 
be obtained from a reliable dairy and 
should be certified as pure and free from 
all preservatives. To insure it from spoil- 
ing after delivery it should be kept on 
the ice until needed for use. Mothers 
or nurses who will neglect these simple 
precautions cannot be too severely criti- 
cised, for they are among the chief sources 
of our alarming infantile mortality. 

Cleansing the Mouth of the In- 
fant. — This is best done by wrapping 
a small piece of sterilized cotton fibre 
around the first finger of the right hand, 
that has been carefully washed with soap 
and sterilized water, and, after moisten- 
ing the cotton in sterile water or a satu- 
rated solution of boric acid, the finger 
is introduced and passed over the surface 



of the month and tongue and particularly 
under the tongue and between the gums 
and cheeks, as these are the places where 
the particles of coagulated milk are 
usually found. If the child is suffering 
from a sore mouth, a physician should 
be consulted at once. 

During the early stages of dentition the 
mouth should be carefully inspected every 
day to see that there are no ulcerations 
of the gums at the points where the teeth 
are making their appearance. If the 
child cries when attempting to nurse, it 
is quite certain that some form of stomati- 
tis — sore mouth — is present and that 
the services of a physician are needed. 
The small ailments of little children 
should never be neglected. It is better 
to have the advice of a competent physi- 
cian in these, as early treatment may pre- 
vent a more serious condition. 

As soon as the teeth begin to appear 
they should be kept scrupulously clean. 
This may be done at first by the method 
already described. After the teeth have 
fully erupted, the tooth-brush will be in- 
dicated. This should be small in size and 
the bristles soft. Camel's hair makes the 



best bristle for the baby's brush. In 
applying the brush especial care should 
be exercised not to bruise or in any way 
injure the gums, or the mucous membrane 
of other portions of the mouth, as these 
tissues at this period are tender and easily 

In the case of infants the cleansing 
of the mouth twice each day will ordinarily 
be sufficient. This should be done morn- 
ing and evening, preferably at the time 
of the bath. After the teeth have erupted 
and the child is taking a mixed diet, the 
mouth and teeth should be cleansed three 
or four times each day, preferably on ris- 
ing in the morning and after each meal, — 
on rising, because the mouth will be found 
to contain a greater number of micro- 
organisms, as they have had an undis- 
turbed period of from six to ten hours 
for growth and propagation. A thorough 
cleansing of the mouth before breakfast 
is more essential to good health, in the 
judgment of the writer, than all other 
measures of personal hygiene combined. 

Persons who suffer from gastric and 
intestinal indigestion — which is often due 
to septic conditions transmitted from the 



mouth — will soon find marked relief from 
their distressing symptoms if they observe 
this rule. They should also visit a com- 
petent dentist and have their teeth put in 
a healthy condition, by having the salivary 
deposits removed, decayed teeth filled, 
abscessed teeth treated, suppurating roots 
removed, and teeth suppurating from 
pyorrhoea alveolaris — Rigg's disease — 
treated or removed. 

After each meal the teeth are fouled 
by food debris, which after two or three 
hours is in a state of fermentation or 
putrefaction, and acids are formed which 
attack the enamel and dentine of the 
teeth, resulting in dental decay. For this 
reason, if no other, the teeth should be 
brushed and cleansed after each meal. 

The writer has always made it a general 
practice to instruct his patients in the care 
of the mouth and teeth. He has often 
been interrogated by his little patients 
who thought it something of a hardship 
to obey the instructions given at home in 
relation to cleansing their teeth. " Doctor, 
how often should I brush my teeth?" 
The question has usually been answered 
by asking another: " How often do you 



wash your face and hands?" 'Why, 
whenever they get dirty." " When do 
your teeth get dirty? " " Why, I suppose 
every time I eat anything." " Then you 
should clean your teeth every time they 
get dirty; and they get dirty every time 
you eat anything. This means at least 
after each meal, and as much oftener as 
you soil them by food or candy" " Can't 
I eat any candy?" " Oh, yes! In mod- 
erate degree it is good for you; but you 
must clean your teeth after eating it, or 
you will suffer from badly decayed teeth 
and a whole lot of other diseases that 
sometimes result from decayed teeth." 

Little children should be taught to use 
the tooth-brush as soon as the imitative 
faculties begin to develop. This may be 
done by the mother or the nurse brushing 
her own teeth before the child, who has 
been furnished with an appropriate brush. 
The lessons, for it will take many, should 
be carefully and slowly taught, so that 
the child will comprehend all the move- 
ments that are required to reach all parts 
of the mouth and teeth. The child should 
be taught to view the teeth in a looking- 
glass to see if they are clean and compared 



with those of the mother or nurse. In 
this way the pride of the child is stimu- 
lated and rivalry awakened to have the 
nicest-looking teeth. 

Of course it is not expected that 
children of three years of age can be 
taught to care for their own teeth; this 
must be the duty of the mother or nurse. 
A beginning, however, can be made at this 
period, and a habit formed as the months 
and years go by, that will cling to the 
child through all after life. The import- 
ance of this early training cannot be over- 
estimated, as it insures mouth comfort, 
good health, and long life, barring 
accidents. The individual who has been 
brought up from early childhood to give 
proper care to the cleanliness of the mouth 
and teeth is rendered quite miserable if 
for any reason he is obliged to neglect 
even for a single day this brushing of the 

The Mouth of the Sick Child. — At 
no period in the life of the child is oral hy- 
giene, or mouth cleanliness, of so much 
importance as during illness. At such 
time the secretions of the mouth are more 
or less changed and frequently are de- 


cidedly acid in reaction; while the micro- 
organisms of the mouth are less disturbed 
than during health, and as a consequence 
grow and propagate more rapidly. Great 
damage is often done to the teeth during 
a short illness from neglect to keep the 
mouth clean. Of course it should be un- 
derstood that during a severe illness it 
may not be possible to carry out a careful 
and thorough regime of mouth cleaning 
on account of the disturbance to the child. 
A little careful cleansing of the mouth and 
teeth will not be harmful to the general con- 
dition of the child at such times, while in a 
majority of instances it will prove restful 
and refreshing. The means already de- 
scribed for cleansing the mouths of infants 
can be employed in these cases with ease. 
If sordes — mucous deposits of dark 
color — form upon the teeth, they can 
easily be removed with a little stick that 
has been shaped like a chisel and charged 
with a little precipitated chalk, and the 
teeth wiped off with a little cotton 
moistened in a saturated solution of boric 

Dextae decay is often established in 
the mouths of little children during 



periods of illness, but much of this can 
be prevented by a proper care of the oral 
cavity during these times. As soon as 
a child has recovered from an illness, its 
teeth should be carefully examined. 
This is best done by the family dentist, 
and, if dental decay has been established 
in any of the teeth, they should be treated 
and filled immediately with materials that 
will arrest the disease and take so little 
time as not to fatigue the child. Many 
little children have to receive the atten- 
tions of the dentist before they are three 
years of age. These children should be 
treated with the utmost gentleness and 
kindness, so as to make it a pleasure for 
them, rather than a terror, to have their 
teeth treated. If the dentist will trouble 
himself to gain the confidence of these 
little ones, he will never have any trouble 
in handling them. 

Toothache and dento-alveolar abscess 
are not uncommon in little children. 
Such affections may become a serious 
menace to the health of the child, either 
through nervous irritation or septic 

The pain from an inflamed dental pulp 



or an acute dento-alveolar abscess is very 
excruciating indeed, as some of our 
readers may know from a personal ex- 

The little child is just as susceptible 
to pain as the adult, but has not the same 
physical power or nervous stability to 
endure it. 





After the completion of first dentition 
at or about the age of three years — the 
eruption of the crowns only is intended 
to be expressed — there is a period of rest 
established so far as the appearance of 
the second or permanent teeth is con- 
cerned. There is, however, during this 
period very active growth or tooth de- 
velopment going on in the jaws, in the 
completion of the roots of the deciduous 
or first teeth, and in the development of 
the crowns of many of the second or 
permanent teeth. 

The roots of the deciduous teeth are 
completed in formation at about the 
following periods and in the order named, 
but no positive rule can be laid down from 
which frequent deviations will not be 



The central incisors are completed at 

about the age of 2 years. 
The lateral incisors are completed at 

about the age of 2J years. 
The first molars are completed at 

about the age of 2J years. 
The cuspids are completed at about 

the age of 2§ years. 
The second molars are completed at 

about the age of 3 years. 

Figs. IV, V, VI show the state of de- 
velopment of the teeth of a child from 
three to three and one-half years of age. 1 

During the period of active develop- 
ment of the teeth the child should be 
guarded against all undue excitement, ex- 
posure, or indiscretions in feeding, as the 
developmental changes which are going 
on are taxing the nervous energy of the 
child to its full capacity. This is the 
period when nervous affections are most 
likely to develop, hence the necessity for 
the caution above expressed. 

1 Photographs from the collection in the Library and 
Museum of the Surgeon-General, U. S. Army. 


Fig. IV. 

Head of Child, aged 3 ' 2 to 4 Years, Front View, showing Com- 
plete Primary Dentition and Secondary Dentition in Various Stages 
of Formation. 

Fig. V 

Right Side of Same. 

Fig. VI. 

Left .Side of Same. 



Normal secondary or permanent denti- 
tion begins at about the sixth year by the 
eruption — cutting — of the first molars, 
which take position behind the second 
deciduous — milk — molars, the growth of 
the jaws having made this possible by in- 
creasing the distance between the second 
deciduous molar and the ascending 
ramus — upright portion — of the lower 
jaw, and between the same tooth and the 
tuberosity — rounded termination — of the 
upper jaw. 

•The growth of the jaws, which keeps 
pace with the eruption of the permanent 
teeth, is mainly confined to an elongation 
of the horizontal ramus of the lower 
jaw — the portion containing the teeth — 
between the second deciduous molars and 
the angle. There is also a certain amount 
of growth taking place at the symphy- 
sis — median line of the chin — and in the 
upper jaw at the median and intermaxil- 
lary sutures — median line of the upper 
jaw and a lateral line passing between the 
lateral incisors and cuspid — miscalled eye- 

2 Marshall's Operative Dentistry, third edition, p. 79. 


teeth— and also in the interstitial sub- 
tance — body of the jaws. 

In this connection it will be well to 
state that, during the process of eruption 
of the permanent teeth of the child, the 
family dentist should be frequently con- 
sulted, so that he may correct at the 
earliest moment any tendency to a mal- 
position of the teeth. It is a mistake to 
postpone such operation until the teeth 
have all erupted, as used to be recom- 
mended not long ago. 

The first permanent molar has the mis- 
fortune frequently to be considered, or 
rather mistaken for, a deciduous or milk 
tooth, and, because of the mistaken notion 
of many otherwise intelligent people, that 
the first teeth should receive no dental 
attention because they are only temporary 
organs soon to be lost by a natural pro- 
cess, these teeth (the first permanent 
molars) are often allowed to decay, until 
they are past saving by any means known 
to the dentist, and have to be extracted. 
A greater crime against the dental per- 
fection of the child could not be com- 
mitted, and the writer wishes he could 
proclaim this fact from the house-tops. 



The first permanent molars are the key- 
stones to the dental arches, and when they 
are extracted the perfection and symmetry 
of the arches are ruined, the teeth assume 
irregular positions, resulting in malocclu- 
sion and more or less loss of the mastica- 
tory function. 

Children whose first permanent molars 
have heen neglected until they are badly 
decayed have usually bad digestion, be- 
cause these teeth have been so sensitive or 
painful as to make proper mastication 
impossible, hence the food has been 
swallowed before it has been properly 
triturated and mixed with the saliva, thus 
producing indigestion, malassimilation, 
headache, general nervous irritability, and 
sluggish minds. Children of this class 
make up the large majority of the " back- 
ward " children in our public and private 
schools. Furthermore these children have 
suffered very considerably in a large 
majority of cases from toothache, or ab- 
scessed teeth and swollen faces, which have 
robbed them of sleep and rendered them 
nervous, peevish, ill-tempered, or posi- 
tively ill; and this many times with little 
or no sympathy from those responsible 



for the upbringing of the child, and who 
have, through ignorance of the conditions 
and the real, vital suffering through which 
the children have passed, considered it as 
one of the children's troubles that must 
be endured. Or, when the cries of the 
child have so disturbed the sleep of the 
household that " endurance was no longer 
possible," the little sufferer has been 
hurried away to the dentist and the tooth 

The following table gives a fairly cor- 
rect idea of the time and the order in which 
the eruption of the permanent teeth takes 
place. 3 These figures are subject to 
slight variations to suit the individual 

First molars .... 5 to 7 years of age. 
Central incisors, 6^ to 8 years of age. 
Lateral incisors, 7 to 9 years of age. 
First bicuspids . . 9 toll years of age. 
Second bicuspids, 10 to 12 years of age. 

Cuspids 11 to 14 years of age. 

Second molars . . 11 -J- to 13 years of age. 

Third molars . . 16 to 21 years of age, 

or at any period later. 

3 Marshall's Operative Dentistry, third edition, p. 81. 

Fig. VII 

Adult Head, showing Complete Secondary Dentition. (After Cryer.) 

Ill 1 1 1 1 Ilflf 


14 The third molars not infrequently fail 
to appear at all. They are usually de- 
veloped, but remain in their crypts in the 
jaws for lack of space in the dental arch 
to accommodate them, or are so malposed 
that their eruption is difficult or im- 

The lower teeth usually precede the 
upper ones of the same class two or three 
months, but this rule is subject to 


The exuviation or shedding of the 
deciduous or milk teeth is a peculiar 
physiologic process — resorption — which 
causes a gradual dissolving or melting 
away of the roots of the teeth until noth- 
ing is left but the crown, which, from 
lack of further attachment to the jaw and 
gum, falls out. 

This process begins in the central in- 
cisors in about a year or a little more 
after the complete formation of their roots, 
Figs. VII, VIII, — viz., in the middle or 
latter part of the third year, — but is not 
completed until about the seventh year, 
when the crowns fall out from lack of sup- 



port, and the permanent central incisors 
take their place. Although these teeth are 
considerably wider than those which they 
replace, the compensating growth of the 
jaw has been such that there is usually 
room for them to take their normal posi- 
tion. IThe lateral incisors are attacked 
a few months later and are shed at about 
seven and one-half to eight years of age, 
the permanent laterals immediately tak- 
ing their place. The process begins in the 
first deciduous molars at the age of six 
and one-half to seven years, terminating 
at about the tenth year ; they are replaced 
by the first permanent bicuspids. The 
second molars are attacked at from six 
months to a year later, the process being 
completed at about the eleventh year, and 
are replaced by the second permanent 
bicuspids. The cuspids are usually the 
last of the deciduous teeth to be shed, 
although many instances will be observed 
in which they will be shed before the 
second molars. The process begins in the 
cuspids at about the eighth year, and is 
not usually conrpleted until the twelfth 
year or even later. These teeth are re- 
placed by the permanent cuspids. The 



location and eruption of the first perma- 
nent molars have already been described as 
situated directly behind the second decid- 
uous molars and they are the most im- 
portant teeth in the permanent dental 
arch. These teeth being members of the 
permanent denture are never shed, which 
is a fact that should be more definitely 
fixed in the lay mind, if the children who 
are born in the future are to maintain 
a normal symmetry of the dental arch and 
of the face. 

At about the twelfth year of age the 
second permanent molars are erupted 
directly behind the first permanent mo- 
lars, and at the sixteenth to the twenty- 
first year of age the third permanent 
molars — miscalled wisdom teeth — take 
their place directly behind the second per- 
manent molars, thus completing the nor- 
mal adult dental apparatus. 


This, primarily, is the consideration of 
all those means which may be employed 
to prevent diseases of the teeth and the 
mouth, and, secondarily \ of those means, 
medical, surgical, and mechanical, which 



are employed to cure disease and to re- 
store parts that have been lost by disease, 
accident, or by design. The former only 
will come within the province of oral hy- 
giene, and is, therefore, the only branch 
of the subject which will be considered in 
these pages. 

The highest aim of the healing art is 
not the cure of disease, but its prevention. 
The Chinese high-class people employ 
their physicians by the year to keep them 
well, to prevent sickness. When any 
member of the family is ill, the pay 
stops — the doctor has been derelict in his 

The highest aim of the dentist should 
be to prevent the development of disease 
within the oral cavity, and to check its 
ravages at the earliest possible moment, 
so that the attendant dangers may be re- 
duced to the minimum. In order to ac- 
complish this much-to-be-desired result, 
frequent examinations of the mouth and 
teeth at stated intervals, with explicit in- 
structions in the various means which may 
be adopted to keep the mouth and teeth 
in an hygienic condition, will be absolutely 



The system of frequent periodical ex- 
aminations, to be most effective, should 
be instituted in early life, commencing 
with the little children as soon as the de- 
ciduous teeth have erupted. In the 
families of the well-to-do and the rich, 
there is no difficulty in the way of its 
accomplishment as soon as they appre- 
ciate its value as a health-giving practice. 
Xot so with the respectable poor and in- 
digent, or the children of the slums, who, 
because of the poverty or ignorance, or 
both, of their parents, rarely or never 
receive such attentions. 

It is hoped, therefore, that the move- 
ment to establish free dental clinics for 
the benefit of the indigent poor may, in 
the light of our advanced and more in- 
telligent appreciation of oral hygiene as 
a public-health measure by the official and 
the general public, prove successful, and 
that the care of the mouth and the teeth 
may become as fully recognized as a 
beneficent service as is now the case when 
illness brings this same class of people 
to our public hospitals and sanitariums. 
Free dental clinics might be established 
as out-patient departments in every pub- 



lie hospital and sanitarium in the country 
with but little additional expense to the 
public treasury. The establishment of 
the great Forsyth Dental Infirmary in 
Boston, Mass., is a most magnificent char- 
ity, and we hope is only the forerunner 
of many like enterprises that will be es- 
tablished by wealthy and philanthropic 
people. The poor and needy are always 
with us, thus making our duty plain. 

Every child that is born into the world 
has the right given of God, to be born 
with a healthy body, a healthy mind, and 
healthful moral tendencies. It also has 
the right to be protected from diseases 
and deformities of body and mind and 
from moral degradation. If parents fail 
in these duties, then the responsibility 
rests with the State. In some instances 
this responsibility is recognized and the 
children protected against the ignorance, 
the indifference, the cupidity, or the in- 
humanity of the parents or guardians. 
The medical inspection of the public- 
school children, recently organized and 
put into operation in several of the States, 
is a recognition of this obligation. But 
it must go much further than at present 



contemplated, and should provide medical, 
surgical, and dental treatment for such 
children as need it, and whose parents 
cannot afford to pay the expense of such 
treatment, while, upon the other hand, 
those who can afford it should be com- 
pelled by stringent law to do so. The 
law compels a father to provide food 
and clothing for his children; why not, 
then, proper medical, surgical, and den- 
tal treatment? 


Many a child becomes ill-tempered, 
morose, cruel, quarrelsome, vindictive, and 
untruthful because of the constant irrita- 
tion of physical defects, not the least of 
which are irritations from dental and oral 
iiseases and malformations. Many a child 
goes wrong morally when it discovers it 
is physically deficient or deformed. A 
crooked disposition often goes with a 
crooked back. 

An irregular set of teeth, a malformed 
jaw, a hare-lip, or a cleft-palate often 
destroys the happiness of a sensitive child 

5 65 


by making him the butt of ridicule of 
his associates, and psychologically tends 
to pervert an otherwise sweet and loving 
disposition, turning it into one in which 
hatred and vindictiveness are its leading 

The State cares for the blind, the deaf 
and dumb, the imbecile, the epileptic, and 
the crippled children. Why should it not 
care for these other children and give them 
a fair chance in life ? — a fair chance to be- 
come healthful, self-respecting, and noble 

Nearly every state that has established 
medical inspection of the public-school 
children, including the District of Colum- 
bia, has included dental inspection. 

The school dental clinics so far estab- 
lished have, as a rule, been supported by 
volunteer subscription and service on the 
part of philanthropic people and dental 
societies and individual dentists. 


Cleanliness of the month and teeth is 
the greatest of all prophylactic measures 
which can be instituted against dental 



This statement needs no verification, 
for it should be patent to every one of 
even limited observation that dental decay 
rarely ever occurs upon the smooth sur- 
faces of the teeth which are fully exposed 
to the friction of foods in mastication 
and the cleansing action of the tongue, 
lips, cheeks, and the oral secretions. 

The prevention of dental decay should 
therefore be directed to securing as nearly 
as possible perfect cleanliness of the 
mouth, for this implies the removal and 
destruction of zymogenic — ferment-pro- 
ducing — micro-organisms of the mouth, 
which are the real cause of dental decay, 
together with their acid products and all 
fermentable material. 

The value of perfect oral cleanliness is 
not generally understood or appreciated 
by the public. Most people brush their 
teeth for purely cosmetic reasons, not to 
prevent disease. It therefore becomes the 
duty of every dental practitioner so to 
instruct his clients in the need of oral 
hygiene as a preventive measure against 
disease, and the means by which they may 
secure this condition, that they will fully 
appreciate its value, and intelligently 



strive to carry out the instruction in all 
of its details. 

These measures should consist of: 

First. Instruction to parents and 
nurses in the proper care of children in 
relation to the general measures of hy- 
giene — food, clothing, exercise, breathing, 
the value of pure air in the nursery and 
plenty of it — that the best possible de- 
velopment of the whole body, and conse- 
quently of the dental organs, may be 

Second. In such a regular and system- 
atic mechanical cleansing of the teeth and 
the mouth that the acid-producing bac- 
teria and the fermentable substances upon 
which they grow may be thoroughly re- 
moved, or reduced to the minimum. 

Third. By prohibiting or so limiting 
the consumption of such foods and con- 
fections as furnish the material for acid 
formation, that the chief source of lactic 
acid may be eliminated or greatly 


A good brush, a spool of floss silk, 
a tongue-scraper, and plenty of pure 



water are all that are needed, ordinarily, 
for cleansing the mouth and the teeth. 
Tooth-powders or pastes may sometimes 
be necessary to keep the teeth bright and 
clean; but when the individual habitually 
brushes the teeth three or four times each 
day, powders and pastes are unnecessary. 
When the teeth are neglected, and 
brushed only occasionally — for instance, 
when going out to dine or to spend the 
evening — dentifrices will most likely be 
needed and plentifully applied to make 
the teeth look passably respectable and 
partially to correct the accompanying un- 
wholesome fetid breath. 

In using the tooth-brush the teeth 
should be brushed both crosswise and up 
and down — that is, in the direction of 
the long axis of the teeth, — with a rotary 
motion, from the gums to the free ends 
of the teeth. This rotating motion per- 
mits the bristles of the brush to pass be- 
tween the dental interspaces of the teeth 
and removes the particles of food that have 
lodged in or have been forced into these 
spaces. These are the locations most fre- 
quently attacked by decay. All the sur- 
faces of the teeth can be reached with 


a properly shaped tooth-brush (Fig. 
IX) . A brush of this form permits every 
tooth to be reached, including the last 
molars, and the surfaces of the teeth next 
to the tongue and the roof of the mouth. 
Tooth-brushes are usually made in three 
grades, " soft," " medium," and " hard." 
The " medium " brush is best for general 
use. 'The " soft " brush is usually too 
soft to be effective in removing the food 
from the interdental spaces, as the bristles 
double up instead of passing into the in- 
terspaces ; while the " hard " brush is fre- 
quently harmful to delicate gums, by 
reason of the fact that the bristles are 
so stiff and wiry as to cause abrasions 
and bleeding. 

The Care of the Tooth-brush. — It 
is important that the tooth-brush be kept 
in a sterile condition, that all danger from 
infection may be obviated. This may be 
accomplished in the home with little 
trouble. The brush should be carefully 
washed after using, with clean water, and 
then immersed in ethyl alcohol. A glass 
jar or bottle of suitable size, fitted with 
a screw top, is the best form of container 
for the purpose that has been found, and 


Fia. IX. 

1 "'"-'■ ~V 

Watkins A.lult Tooth-brush. 


Watkins Child's Tooth-brush. 


does away with the necessity for boiling 
the brush. 

In a neglected and unclean mouth the 
gums are often in a state of considerable 
congestion and inflammation; under such 
circumstances the softest brush will cause 
hemorrhage, but after a time, if the brush- 
ing is persisted in, the tendency to hem- 
orrhage will cease, and the gums will 
assume a healthy appearance, provided 
the salivary deposits — tartar — have been 
removed and the surfaces of the teeth 
properly polished. 

The use of " silk floss m as an ad- 
junct to the tooth-brush is of great value 
in cleansing the dental interspaces of such 
particles of food as the tooth-brush has 
failed to remove. The silk should be first 
waxed and then cut in pieces six to eight 
inches in length, and these passed between 
the teeth, and by a backward and forward 
movement made to pass over the approxi- 
mating surfaces of the teeth from the 
gums to the cutting edges or the grinding 
surfaces. Care should be used not to 
wound the gums by forcing the silk upon 
them with too great energy. 

Tooth-picks are also useful in removing 



food debris and vegetable and animal 
fibres that have been forced between the 
teeth and are impinging upon the gums. 
Such masses of food should never be al- 
lowed to remain impinging upon the 
gum for a longer time than one can reach 
a convenient place for their removal, as 
great injury may be done to the delicate 
festoon that fills the base of the dental 
interspace and gives to the gums their 
beautiful symmetry. The loss of the gum 
festoons gives the appearance of age or 
senility to the teeth ; they should therefore 
be protected from injury and loss. Un- 
skillful use of the tooth-pick is often very 
harmful to the gum festoons, and for that 
reason it should be rarely used. Metal 
tooth-picks are unpleasant to use, espe- 
cially if the individual has metal fillings 
in the teeth, because when two dissimilar 
metals come together in the mouth a 
galvanic shock is the result; furthermore, 
they can rarely be made thin enough to 
pass properly between the teeth. Wooden 
tooth-picks are an abomination, for they 
are too thick and clumsy to enter the den- 
tal interspaces, and they often break off 
between the teeth or split and leave 



slivers in the gums that cause inflamma- 
tion, suppuration and sometimes sepsis. 

The only tooth-picks that should be 
used in the mouth are thin, sterilized 
quills, made from suitable feathers. 
These can be used without injury to the 
tissues, and, if scraped thin enough, will 
readily pass between the teeth; while they 
are sufficiently rigid to remove vegetable 
and animal fibres that may have lodged 
between the teeth. 

The tongue is often in a very unsani- 
tary condition. This organ should receive 
as much attention as is given to the teeth 
to keep them clean. The dorsum — upper 
surface — of the tongue is supplied with 
numerous minute papillae and tiny grooves 
or depressions surrounding them, which 
are the lodging-places for particles 
of food debris and are the breed- 
ing-ground for vast numbers of micro- 
organisms. The dorsum of the tongue 
should be cleaned every morning 
by scraping with a suitable instrument 
made of ivory, bone, or celluloid. It 
should be about six inches long, thin in 
the middle and thicker at the ends so 
that on bringing the ends together it will 



form a bow. This instrument is to be 
carried back to the root of the tongue and 
drawn forward upon the surface several 
times. The Japanese provide a tongue- 
scraper with every tooth-brush sold. This 
would be a good practice for all tooth- 
brush manufacturers to adopt. The tooth- 
brush may be used for the same purpose, 
but it is inferior to the scraper and less 
comfortable to use. 

The writer has occasionally lost a client 
by his insistences that greater care must 
be exercised upon the part of the individ- 
ual in keeping the mouth and teeth clean 
if he has to be retained as the dental 
attendant, or because he declined to act 
the part of a scavenger for the removal 
of such accumulation as could be easily 
gotten rid of by the use of the tooth-brush 
before presenting for treatment. 

Many ladies who are pinks of perfec- 
tion and neatness in their toilet, wear beau- 
tiful clothes, and expensive diamonds and 
pearls about their necks, are wofully 
negligent of mouth cleanliness, neglecting 
the pearls in their mouths until they turn 
black and unsightly from neglect and 
disease — through an unreasoning fear of 



dental treatment — and constantly carry 
about with them conditions infinitely more 
dangerous to their individual health and 
more disgusting to their associates than 
the sight and smell of an open sewer. 


These agents are of little value except 
as toilei articles. They have little or no 
inhibitive effect upon the micro-organ- 
isms that inhabit the mouth. An antisep- 
tic of sufficient strength to inhibit the 
growth of any mouth bacterium would 
prove so irritating to the mucous mem- 
brane that it could not be borne. The 
only real value of a mouth-wash is to 
assist in keeping the mouth clean, in con- 
junction with the tooth-brush, to correct 
or disguise an offensive breath, or, by its 
cooling and detergent effect, to allay an 
inflammatory condition of the mouth in- 
duced by neglect or disease. As a means 
of preventing the growth of mouth bac- 
teria or of preventing decay they are " a 
delusion and a snare." Mouth cleanliness, 
produced by mechanical means, is the only 
preventive of these conditions. The mere 
rinsing of the mouth with fluids does not, 



and cannot, remove the food deposits left 
upon the teeth after mastication. 

Clean teeth do not decay. — A clean 
mouth and a clean body are the best safe- 
guards against disease. Guard well the 
health of the mouth and the stomach will 
take care of itself. Keep the mouths and 
teeth of the children in a clean and healthy 
condition and the undertaker will call less 
often at your door. 




At no time in the history of the individ- 
ual is the proper hygienic care of the 
mouth of so much importance as when 
suffering from severe and prolonged ill- 
ness; especially the continued and inter- 
mittent fevers, tuberculosis, acute articu- 
lar rheumatism, nervous prostration, and 
during pregnancy and lactation. 

During these periods there is always 
a marked change in the character of the 
oral secretions: instead of being neutral 
in reaction they are almost invariably acid, 
while the patient will often complain of a 
" bad taste in the mouth." These condi- 
tions are due to perverted nutrition, 
faulty metabolism and the action of the 
mouth bacteria. 

Rapid dental decay, gingivitis — in- 
flammation of the gums — and stomatitis 
are common complications, or rather 
sequelae, of severe illness. 

Rapid dental decay is almost always 



a concomitant affection of typhoid fever 
and rheumatic fever. The same condi- 
tion is also very frequently associated with 
pregnancy and lactation. These facts 
are well known to dental surgeons, and 
many cases might be cited to substantiate 
the statement. 

By way of ilustration, the writer will 
briefly describe three typical cases from 
his own practice: 

Mr. J. K., aged 19 years, in the best 
of health, had his teeth put in good con- 
dition before entering college. He had 
had but little dental decay; always from 
early childhood had taken nice care of his 
teeth and mouth. Was considered by the 
writer as one of his banner patients. 
Two months after entering college, he 
was stricken with typhoid fever in a severe 
form. Three months later he returned to 
his home to convalesce, and at once re- 
ported complaining of sensitiveness of the 
teeth and of decay. Upon a critical ex- 
amination, fourteen cavities of decay were 
found, located at the gum margins and 
upon the approximal surfaces. 

Miss E. L., aged 14 years, of robust 
health, had beautiful and almost perfect 



teeth, with very few fillings. Mouth care- 
fully examined just before sailing for 
Paris to enter a fashionable school. Six 
months later was stricken with inflamma- 
tory rheumatism, and for several weeks 
her life hung in the balance. Upon re- 
covery she visited a noted Paris dentist 
for relief of very severe pain and decay 
at the gum margins of nearly all her 
teeth. Only temporary treatment was 
given her at this time, as her parents were 
to bring her home as soon as strong 
enough to make the ocean voyage. She, 
however, suffered a relapse and died in 

Miss H. C, aged 25 years. Milliner 
by occupation; health had been good. 
Teeth were in good condition and regu- 
larly cared for. Had a number of fillings, 
all in good condition at last visit. Soon 
after was stricken with pneumonia and 
was desperately ill and made a slow re- 
covery. Acute pulmonary tuberculosis 
developed before she was able to leave her 
room, and from which she died six months 
later. During the last four months of 
her illness her teeth were attacked with 
rapid decay, which affected nearly every 



metal filling in her mouth and established 
several new cavities, necessitating many 
visits to her bedside to give her relief from 

In all abnormal affections and conditions 
the salivary secretions are hyper-acid, and 
as a result of this the teeth are particularly 
prone to rapid dental decay. The same 
is true of children suffering from severe 
and prolonged cases of scarlet fever, diph- 
theria, measles, and gastro-intestinal 
affections. The writer also observed 
while on duty in the Philippine Islands 
that our soldiers afflicted with amoebic 
dysentery and sprue were very prone to 
rapid dental decay. 

The signs of rapid dental decay are a 
whitening of the enamel at the cervices — 
necks — of the teeth at the gum margins, 
giving a chalky appearance to this portion 
of the teeth, a whitened or chalky zone 
around present cavities of decay, and the 
formation of chalky appearing zones upon 
the approximating surfaces of the teeth 
at the points of lateral contact. 

Gingivitis, or inflammation of the 
gums, is usually due either to an unclean 
condition of the mouth, causing an in- 



fection, the presence of salivary calcu- 
lus — tartar — or to a faulty metabolism. 

Stomatitis, or inflammation of the 
mouth, is generally due either to infection 
from an unclean mouth, to local irrita- 
tion from substances taken into the mouth 
as food or remedies, or to the action of 
drugs, such as mercury, iodine, and the 
mineral acids, which have been exhibited 
for systemic purposes. 

The care of the mouth of the 
invalid is a subject of great importance 
from both the hygienic and curative stand- 

The first consideration in prophylaxis, 
or prevention, is cleanliness. This applies 
with equal force to medicine, surgery, and 
sanitation. It is the sheet-anchor of suc- 
cess in all of these departments of science. 

The oral hygienist must therefore base 
his expectations for success upon cleanli- 
ness of the mouth, first, last, and all the 

The physician insists upon the daily 
bath of all his patients, suited of course 
to their particular case. The surgeon 
not only requires this, but insists that 
the part to be operated upon shall be 

6 81 


rendered surgically clean — germ free — 
which is a much more exacting proposi- 
tion than ordinary cleanliness. The den- 
tist also requires that the tooth upon which 
he operates shall be surgically clean, and 
this he accomplishes by isolating the tooth 
with sterilized rubber dam and treating 
the tooth with antiseptics. 

The oral hygienist cannot, however, 
carry his efforts in cleanliness to the ex- 
treme required by the surgeon and the 
dentist; neither is it necessary in order 
to accomplish the success for which he is 

The fact remains that in the mouth 
which is free from food debris, accumula- 
tions of salivary calculus, decayed teeth, 
or diseases producing suppurative pro- 
ducts, the fluids of the mouth have no 
auto-infective properties. In other words, 
the secretions of a clean, healthful mouth 
are physiologic products, although they 
may contain several species of mouth or- 
ganism and be infective to another in- 
dividual. Wounds, even of an extensive 
character, made in a clean mouth almost 
invariably heal without inflammation or 
other untoward accompaniment. 



In the case of the mouth of the invalid 
who has been accustomed, previous to the 
present illness, to give proper attention 
to the cleanliness of the mouth and dental 
treatment, there are no difficulties that 
may not be overcome with tact and 
patience. In even the most desperate 
cases, where the temperature is running 
high and the mouth, tongue and lips are 
dry and parched, a gentle cleansing of 
the mouth is most soothing and grateful 
to the patient and eagerly sought there- 
after; and, instead of being disturbing 
and harmful to the invalid, proves restful, 
as is often shown by being followed by 
refreshing sleep. It is not always pos- 
sible to employ the tooth-brush and water 
for cleansing the mouth, as the patient 
may be too weak to sit up or even to 
turn over on the side to eject the water 
from the mouth. Under these circum- 
stances the mouth may be effectively 
cleaned by first wiping the teeth with 
a piece of sterile gauze, wrapped upon the 
first finger of the right hand or upon an 
orange-wood stick — the finger being 
preferable for many reasons which are 
obvious — moistened in a two per cent. 



solution of carbolic acid or a saturated 
solution of boric acid. Then with the 
orange-wood stick, flattened at one end 
and wrapped with a few fibres of steril- 
ized cotton, carefully rub the surfaces of 
all the teeth with a twenty-five per cent, 
solution of hydrogen peroxide, complet- 
ing the cleaning of one tooth at a time. 
The foam which is caused by the effer- 
vescence of the hydrogen peroxide in con- 
tact with the fluids of the mouth may be 
wiped away with pieces of gauze moist- 
ened in orange water. This cleansing will 
usually prove so grateful and refreshing 
to the invalids that they will look forward 
to it with pleasurable anticipations. 

The cleaning of the tongue is a very 
important matter in all cases of severe 
illness, especially when the tongue is con- 
stantly covered with a thick, heavy de- 
posit — fur, — the result of rapid and un- 
disturbed growth of micro-organisms. 
In these cases the tongue-scraper will be 
an invaluable aid to a proper cleaning 
of this organ. The tongue should be care- 
fully wiped afterwards with a piece of 
sterilized gauze moistened with a satu- 
rated solution of boric acid for its cleans- 
ing effect. 



The cleansing of the tongue, aside from 
its prophylactic value, is a matter of great 
comfort to a patient with a high tempera- 
ture, and should never be neglected when 
it is possible to accomplish it without too 
much disturbance of the patient. 

On the other hand, with a patient who 
has never given any particular attention 
to the cleanliness of the mouth or to den- 
tal treatment, in which salivary calculus 
is present in considerable amount, den- 
tal decay rampant, several teeth with dis- 
charging abscesses, or suppurating sock- 
ets from pyorrhoea alveolaris — Riggs's 
disease — many difficulties are presented; 
difficulties which cannot be overcome ex- 
cept by a dentist or a dental nurse trained 
for this particular service. There is great 
need in all our hospitals and sanitariums 
for nurses of this character, — genteel 
young women who have received special 
training to fit them to take charge of 
general mouth hygiene, to remove salivary 
calculus, relieve pain from exposed pulps, 
treat abscessed teeth and other suppura- 
tive conditions of the mouth under the 
direction of the dental attendant. 

Except in very uncleanly and badly 



diseased mouths, the nurse will be able 
to render considerable relief and give 
much comfort to her patients by following 
the regime just laid down. 

As soon as a patient is strong enough 
to sit up in bed, the tooth-brush should 
be used, rinsing the mouth with sterile 
water or a saturated solution of boric 
acid flavored with orange water for its 
refreshing effects. 

It is never wise to prolong the process 
of mouth cleansing to the point of causing 
fatigue, as this would be harmful. Gen- 
tleness of touch, dexterity of manipula- 
tion, and a sympathetic manner will soon 
allay all nervous apprehensiveness upon 
the part of the patient ; for it is a peculiar 
fact that most people have a nervous 
dread of dental manipulations. 

In the treatment of mouths affected 
with rapid dental decay from the hyper- 
acid condition already mentioned, the 
deleterious effects of the acids upon the 
teeth may be counteracted by the frequent 
use of alkaline or antacid solutions, such 
as bicarbonate of soda, one teaspoonful to 
half a glass of tepid water, or milk of 
magnesia, one tablespoonful to half a 



glass of tepid water, or lime water in the 
same proportions. 

Pregnant and nursing women cannot 
be too careful about their mouth condi- 
tions, as their teeth are prone to dental 
decay during these periods. The old say- 
ing among midwives, which goes back 
to the early history of civilization, " For 
every child a woman bears she loses a 
tooth," though not absolutely true, is 
based upon the observed fact that during 
pregnancy and lactation dental diseases 
are much more prevalent and serious than 
during other periods and that teeth are 
frequently lost during these periods. 
Perverted oral secretions, gastric indiges- 
tion, malnutrition, and faulty metabolism 
are doubtless the underlying causes. 

Many of these women suffer from in- 
flamed and bleeding gums. This is in all 
probability due to plethora of the upper 
part of the body induced by the known 
increase in the volume of blood during 
pregnancy, and by impeded circulation 
resulting from the pressure of the gravid 
uterus upon the descending aorta. 

Pregnant women should protect them- 
selves against the loss of their teeth by 



frequent visits to the family dentist. No 
woman who can prevent it should allow 
herself to approach the lying-in period 
with her mouth in an unclean or diseased 
condition, as septic conditions of the 
mouth are exceedingly dangerous to the 
lying-in woman. Many accoucheurs are 
now so impressed with this fact that they 
insist upon their patients having all septic 
teeth rendered sterile by proper dental 
treatment or extracted before the lying- 
in period, or refuse to be held responsible 
for the after results if sepsis follows 
parturition. Many surgeons dislike to 
operate, especially in abdominal cases 
or general non-septic cases, until the 
mouth and teeth have been carefully in- 
spected for septic conditions, and, if pres- 
ent, cured or removed. 

Only a few years ago no such thought 
was given to the possible dangers to the 
success of a delivery or of a surgical 
operation from a septic condition of the 
mouth. These facts are becoming more 
and more widely recognized by the pro- 
fession, and with corresponding benefit 
to suffering humanity. 

Pregnant and nursing women fre- 



quently complain of excessive sensitive- 
ness of their teeth to changes of tempera- 
ture and to sweets and acids. This con- 
dition is usually due either to an unclean 
condition of the mouth with acid fermen- 
tation of food debris or to dental decay, 
either superficial or progressive in its 
character. This may be overcome by 
thorough cleanliness of the mouth, the 
treatment and filling of the decayed teeth, 
and the use of bicarbonate of soda, milk 
of magnesia, or lime water as indicated on 
a previous page. 




The American people can rightfully 
be charged with two great sins against 
physiologic living: First, that of bolting 
their food, insufficiently masticated and 
inadequately mixed with the natural se- 
cretions of the mouth; second, that of 
drinking large quantities of iced water 
with their meals. Two greater handicaps 
to a normal digestion could not have been 
invented, even by the evil one himself. 

Insufficient mastication and inadequate 
insalivation of food place work upon the 
stomach which should have been per- 
formed by the teeth and the salivary 
fluids. Drinking iced water chills the 
stomach contents and retards digestion. 
As a result of these two vicious habits, 
we are fast becoming a nation of dyspep- 
tics, whose minds are filled with pessimis- 
tic ideas and who are doing much to sour 



the milk of human kindness by our sombre 
views of life. 

No man, woman, or child can be op- 
tismistic in their views of life, or be good- 
natured and happy in mind or physically 
full of life and energy who has a dis- 
ordered dyspeptic stomach. 

Bolting the food improperly masticated 
is, however, not always the result of the 
hurry-up habit which so afflicts the aver- 
age American ; but is often due to decayed 
and sensitive teeth with exposed pulps, 
which make mastication a torture, or to 
teeth loose and sore from abscesses or 
from pyorrhoea alveolaris, or from a loss 
of so many teeth as to make mastication 
impossible. In the latter case this de- 
ficiency can be corrected by the insertion 
of artificial teeth; while the former con- 
ditions may be cured or greatly mitigated 
and relieved by appropriate dental treat- 
ment, and the adoption of a suitable hy- 
gienic regime, such as the one already 
outlined in a preceding chapter. 

Hygienic living, beginning with a clean 
and healthful mouth and proper mastica- 
tion of food, will soon cure dyspepsia and 
banish many other ills that are only reflex 



symptoms dependent upon the disordered 

Dr. Gustave Fuetterer, 1 in an article on 
" Round Ulcer of the Stomach followed 
by Carcinoma," calls attention to the fact 
that this form of ulcer located at the 
pyloric orifice of the stomach becomes 
carcinomatous through the irritation 
caused by mechanical rubbing or friction 
from particles of improperly masticated 
food, such as crusts of bread and hard 
or crispy portions of fried or baked 

What is proper mastication? This 
question is often asked, and may be 
tersely answered in the words of the 
"Grand old Man" William E. Glad- 
stone, late Prime Minister of Great Brit- 
ain. Being asked by a friend to what he 
ascribed his robust health and long life, 
he replied, " To thorough mastication of 
my food." When asked what he meant 
by thorough mastication, he replied, " Na- 
ture has given me thirty-two good teeth, 
so I aim to give every morsel of food 
that enters my mouth thirty-two bites." 
A better answer to this question could not 
be found. 

1 Journal American Med. Asso., March 15, 1902. 


Mr. Fletcher, the American Apostle 
of Right Living, says, " All food should 
be masticated until it is practically lique- 
fied before it is swallowed." Such masti- 
cation or trituration of the food places 
it in the best possible condition to be 
quickly acted upon by the digestive fluids 
of the stomach, thus preventing fermen- 
tation and the production of ptomaines — 
poisonous products of decomposition. 

When food is swallowed imperfectly 
masticated and improperly mixed with 
the oral fluids, fermentation is soon es- 
tablished, with the formation of malodor- 
ous gases, which cause discomfort or pain, 
and constantly annoy the sufferer by 
being belched from the mouth; or 
ptomaines are formed from decomposi- 
tion, producing septic inflammation of 
the stomach and bowels, with diarrhoea. 
Shakespeare says, " Appetite waits on 
good digestion." But we may go a step 
further and say, good assimilation waits 
on good digestion, and good health on 
good assimilation. 


Children should be taught early in life 
correct methods of breathing. Many 



children habitually breathe through the 
mouth, simply because they have not been 
taught to breathe through the nose, and 
not because there are any obstructions 
in the nasal passages. On the other hand, 
many children are forced to breathe 
through the mouth because of narrow or 
obstructed nasal passages or abnormal 
growths in the upper pharynx. When a 
child cannot breathe freely through the 
nose, the attention of the physician should 
be immediately called to this condition and 
proper treatment undertaken at once. 

A child who habitually breathes 
through the mouth will almost certainly 
be dull mentally, irritable in disposition, 
have frequent attacks of sore throat, 
tonsillitis, severe colds and bronchitis, and 
will be predisposed to pulmonary dis- 

Associated with abnormal growths in 
the nasal passages there will be found 
almost invariably a narrow V-shaped or 
saddle-shaped upper jaw, which contracts 
the nasal passages and makes nasal 
breathing difficult, even without the ob- 
structions. If, as sometimes happens, this 
is complicated with a deviated septum — 



inner division of the nose — the condition 
is a serious one and calls for a consulta- 
tion with a nose and throat specialist and 
a dentist, preferably an orthodontist — one 
who regulates the teeth. The work of 
the nose and throat specialist will be to 
clear the nasal passages of abnormal 
growths or conditions; that of the ortho- 
dontist will be to expand the dental arches 
and bring the teeth into a proper align- 
ment and normal occlusion, and by so 
doing expand the nasal passages, thereby 
giving the patient a normal breathing 

Children may be taught to breathe cor- 
rectly by having them stand erect, with 
the shoulders thrown back, and the lips 
tightly closed, while they slowly fill the 
lungs by taking in the air through the 
nose and as slowly expel it through the 
same channel. Children who cannot do 
this after repeated trials without opening 
the lips will be found to have nasal ob- 
struction and in need of treatment. 
Breathing, to be natural, should be with 
the diaphragm and the abdominal muscles. 
Raising of the shoulders while filling the 
lungs under forced inspiration should be 



strictly prohibited, as this develops a 
faultly method of breathing, often seen 
in female singers upon the stage. Girls 
should be taught that a tight corset or 
other tight clothing about the waist pre- 
vents normal breathing and tends to pro- 
duce disease. 

Nature has provided the nose with a 
peculiar bony structure known as turbin- 
ates — bones rolled in a spiral form — to 
increase the surface of the air-passages 
over which the air must pass on its way 
to the lungs. The nasal pasages, includ- 
ing the turbinates, are covered with a 
peculiar ciliated mucous membrane, and 
studded with numerous little glands which 
constantly bathe this membrane with a 
thick, tenacious fluid, over which the air 
must pass on its way to the lungs. Sit- 
uated just within the nostrils are also a 
great number of tiny hairs. These small 
hairs, the cilia — tiny projections — and the 
fluids are provided by nature for the pur- 
pose of purifying the air thus passing to 
the lungs of particles of dust and other 
irritating substances and many micro-or- 
ganisms floating in the atmosphere. To 
rob the system of the benefits of free 



breathing through normal passages is to 
invite disease, to handicap our children 
physically and mentally, and possibly to 
lay the foundation for premature death. 

The introduction of the out-door school 
is a movement in the direction of improv- 
ing the health of the children so handi- 
capped and wall doubtless do much to- 
wards lessening the number of contagious 
and infectious diseases ; but operative pro- 
cedures will still be necessary to relieve 
the obstructed nasal passages and to en- 
large these passages by the expansion 
of the dental arches. 

Good blood can only be made from 
good food properly masticated, digested, 
assimilated, and oxygenated. Proper 
mastication cannot be accomplished with- 
out good teeth, Normal digestion is im- 
possible without proper mastication. 
Perfect assimilation is impossible without 
normal digestion. Normal oxygenation 
is impossible without free, unobstructed, 
and healthy air-passages and plenty of 
pure air. 




The principles of oral hygiene are so 
simple that any child of school age, with 
ordinary intelligence, can understand 
them. There is, therefore, no reason upon 
that ground why the teaching of oral hy- 
giene may not become a part of the 
curriculum of our public schools. It 
would not be necessary to teach the child 
all the reasons why (oral cleanliness is 
essential to a vigorous body and mind, 
but he or she can be taught how to keep 
the mouth clean, and some of the more 
patent and simple, social and cosmetic 
reasons therefor, reserving the more 
scientific reasons, such as belong to in- 
dividual health, public health, increased 
mental capacity, longevity, and its influ- 
ence upon posterity, to the higher schools. 
No school curriculum, however, should be 
considered complete that does not provide 
for the teaching of this department of 
sanitation. This necessity must be self- 



evident, from the facts presented in the 
foregoing pages. 

There is, however, much prejudice to 
be overcome, by those interested in this 
sub j ect, upon the part of physicians, pub- 
lic-health boards, school boards, teachers, 
and parents themselves. This prejudice 
is in some instances due to a lack of 
knowledge or appreciation of the fact 
of the very close relationship which exists 
between an unhealthy and unclean mouth 
and many very serious general diseases 
of the body, such as tuberculosis, gastri- 
tis, gastro-enteritis, pneumonia, diphthe- 
ria, etc.; or of the very close relation- 
ship which exists between affections of the 
teeth and certain diseases of the eyes, the 
ears, the accessory sinuses of the mouth 
and nose, or of many reflex neuroses de- 
pendent upon dental diseases, or of the 
relationship which epilepsy and insanity 
sometimes bear to diseased teeth 

In other instances this prejudice is the 
result of ultra-conservatism. " The old 
way is good enough." " Why should we 
take up every new fad that comes along? " 
" Our children are better cared for than 
we were, and yet they are no more robust 


in body or brighter in mind than was our 
generation." These people forget the 
change in environment that has taken 
place since their school days. Then the 
population was widely scattered over 
large country districts, with their pure air, 
wholesome food, early hours, and simple 
pleasures largely enjoyed in the open air. 
Now the population is largely crowded into 
cities, wath their fetid air, unwholesome 
food — food gathered green and ripened 
in transit — stale vegetables, cold-storage 
meats and eggs, impure, doctored milk, 
adulterated or poisonous preserved or 
canned fruits, vegetables, and meats: un- 
wholesome drinks served at the soda foun- 
tains, the syrups made by synthetic chem- 
istry instead of pure fruits and grape 
sugar: badly ventilated and over-heated 
houses, school-rooms, churches, and pub- 
lic halls; stuffy street-cars and railroad- 
coaches; their late hours and exciting 
pleasures. No wonder these children are 
no more robust and no brighter in mind 
than were the children of the generation 
that immediately preceded them. The 
wonder is that so many have survived 
under the handicap placed upon them. 


Others will be prejudiced against it 
on account of the expense attached to its 
teaching and practice. This will be the 
objection most often raised by the school 
boards. With little effort it can be proved 
to the satisfaction of these gentlemen that 
oral hygiene taught and practised in the 
public schools will be a wise economic 
measure, as it improves the general health 
of the children, betters their conduct, in- 
creases their mental activity and capa- 
city, lessens truancy, and greatly re- 
duces the number of days lost from ill- 
health, as is shown by the reports of Dr. 
Ebersole and Miss O'Xeill (which will 
be found in Part III, Chapter XV), 
while it greatly reduces the number of 
children who fail to pass their examina- 
tions and have to remain a second or a 
third year in the same grade. Illness im- 
poses a heavy drain each year upon the 
funds of the school boards in our large 
cities, and has been for many years one 
of the serious problems discussed by them. 
The question of how to overcome it has 
never been answered until now. The 
work done at the Marion School of Cleve- 
land, Ohio, has blazed the way for the 


anxious school boards, and has demon- 
strated, to those who are interested in the 
subject of oral hygiene, that this depart- 
ment of sanitation will prove to be one 
of the greatest factors in the conserva- 
tion of the public health; an equally im- 
portant factor in correcting the ever-in- 
creasing delinquency list in our public 
schools; adding to the physical comfort 
and happiness of the children generally; 
improving their health; clearing their 
minds; making study a pleasure instead 
of a bore, and improving the general con- 
duct of the school Where health abides 
happiness abounds. cc The health of the 
people is the supreme law/' 




In most of the public schools in the 
poorer districts of our large cities it is 
usually the duty of at least one teacher 
to inspect the children as they enter the 
school building to see if their hands and 
faces are clean and if the hair has been 
properly brushed or dressed. Children 
who are not clean are either sent home 


or to the toilet room to clean up before 
they are admitted to the school-room. A 
few lessons of this character soon show 
their good effects upon these careless or 
neglected children and upon the homes 
from which they come. 

A similar course might be pursued in 
relation to the teeth. The teacher could 
ask each child to show its teeth upon pass- 
ing her, and if they were not clean, the 
child's attention should be called to the 
fact and informed that the teeth should 
be cleaned after every meal. If the 
parents are too poor to furnish a tooth- 
brush for each of their children, then those 
who attend the school should be furnished 
with one at the public expense, and the 
child taught how to use it and care for it. 

A better scheme would be to furnish 
every child in the school with a tooth- 
brush properly tagged for identification. 
The tags should be of metal, and stamped 
with the number of the room to which 
the child belongs, his or her initials, and 
seat number if the children are seated in 
this manner. The brushes of each room 
should be kept by themselves in a special 
receptacle, preferably a large glass jar 



with a ground-glass stopper. The brushes 
should be washed and sterilized by steam, 
or ethyl alcohol, after each use, and then 
immediately placed in their proper re- 
ceptacle. By this plan there would be 
no danger from the transmission of dis- 
ease from one mouth to another. 

The objects of this plan are two-fold: 
First, it makes it possible to give the 
children a daily lesson in how to clean 
their teeth, and, second, it makes it pos- 
sible to secure at least one good cleansing 
of the teeth each school day. In order 
to carry out this plan successfully a tooth- 
brush drill must be organized and prac- 
tised every day. Ten or fifteen minutes 
devoted to this exercise each day would 
be of great value to these children. Ac- 
companying the drill should be. a few 
words of explanation from the teacher 
as to why the teeth and mouth should 
be kept clean, — its advantages to health, 
beauty, and mental activity, also to its 
commercial value as they arrive at an age 
when they are seeking employment. A 
boy or girl, looking for employment, who 
has a dirty, ill-kept mouth and teeth will 
have a hard time to find a situation, as 



this condition shows slovenly habits and 
most business men are afraid to employ 
such people for fear these methods might 
be pursued in their business. A boy or 
girl with a bright face, a clean, wholesome 
mouth and teeth, and a pleasant smile, 
does not labor under such a handicap as 
this and, as a rule, readily finds employ- 

The writer believes it would be a dis- 
tinct advantage to public health if every 
grammar school could be supplied with a 
trained nurse who should be on duty dur- 
ing the school hours to look after the 
sanitary conditions; to advise with the 
principal and to take care of the children 
who complain of being ill, to render first 
aid in case of accidents, to assist the medi- 
cal and dental school inspectors when 
making their periodical examinations; to 
have charge of the cleansing and steriliz- 
ing of the tooth-brushes, and of the tooth- 
brush drill. 






Sepsis, — putrefaction ; infection with 
pathogenic micro-organisms. 

Septic , — putrid; a septic substance is 
a putrid substance; that which produces 
or results from putrefaction; rotten. 

Sepsis, from the medical and surgical 
stand-point, is the effect or resultant of 
the decomposition of necrosed or dead 
animal tissue, either in molecular form 
or en masse, by a process induced by the 
action of certain non-pathogenic germs — 
non-disease-producing — or saprophytic 
germs, and the formation of ptomaines — 
animal poisons — and their absorption by 
the general system. 

It also includes infection with patho- 
genic — disease-producing — germs, such as 
the pyogenic — pus-producing — micro-or- 
ganisms, the Koch or cholera bacillus, the 
bacterium typhosus — the typhoid-fever 
germ — the bacillus tuberculosis — the germ 
of tuberculosis — and many others. The 
saprophytic germ can live and grow only 



in dead and dying tissues, but may be- 
come the cause of disease by indirect 
measures — the formation of animal pois- 
ons and their absorption — producing what 
is known as septic poisoning. The pyo- 
genic — pus-producing — micro-organisms 
live and grow in living tissues, destroying 
the vitality of the cellular elements 
and converting them into pus-corpuscles. 
There are several varieties of these pyo- 
genic organisms, some more virulent than 
others. The effect of infection with the 
pyogenic organisms will always vary with 
the virulence of the organism, the size of 
the dose, or quantity introduced, and the 
susceptibility of the tissues infected, in 
other words, to their resistance or the re- 
sistive power of the general system. 

The human mouth in a diseased con- 
dition contains many of the most virulent 
septic micro-organisms, especially those 
associated with decayed teeth containing 
devitalized or gangrenous tooth-pulps, — 
acute and chronic dento-alveolar ab- 
scesses, gingivitis, stomatitis, and py- 
orrhoea alveolar is. 

Hunter William is of the opinion that 
the most virulent of all the pyogenic or- 


ganisms are those associated with necrosed 
bone and tooth structure. 

Suppurative or septic conditions of the 
mouth are exceedingly common and are 
in a large majority of cases associated 
with the teeth. The statement has already 
been made, and the fact is recognized, 
that dental disorders are the most com- 
mon of all diseases that afflict the human 
race and that many obscure diseases affect- 
ing the general system — such as chronic 
dysj3epsia, gastritis, gastro-enteritis, cer- 
tain nervous affections, tonsillar diseases, 
pharyngitis, bronchial and pulmonary 
affections, certain diseases of the eye and 
ear, and general septic conditions such 
as septicaemia and pyaemia — may be traced 
to infection from a septic oral cavity. 

A septic oral cavity is generally, if not 
always, the result of neglectful habits, 
due usually to ignorance of the dangers 
to health and life that surround such con- 
ditions. Xeglected dental plates, bridges, 
and crowns, faulty fillings, deposits of 
food debris, salivary calculus, dental de- 
cay, gangrenous dental pulps, acute and 
chronic dento-alveolar abscesses, pyorrhoea 
alveolaris, gingivitis and stomatitis in their 


various forms, are all active factors in 
producing a septic mouth. 

Dental surgeons have been trying for 
years to impress this fact upon their pa- 
tients and upon the medical profession 
generally, but it has usually fallen upon 
indifferent or deaf ears. With a few re- 
markable exceptions, they have until quite 
recently made but few converts among 
medical men. These gentlemen have, as 
a rule, looked askance at any opinion upon 
a medical and surgical subject coming 
from a dental surgeon, believing that 
" The shoemaker should stick to his last." 
This attitude has doubtless retarded the 
just recognition of oral sepsis as an 
ever-present menace to individual and 
public health. The subject is one of 
vast importance from a public-health 
stand-point, not second to any other sub- 
ject that concerns the physical and mental 
welfare of the people, for it strikes at 
the very foundations of the race in that 
95 per cent, of all the public-school chil- 
dren are suffering from it, and as yet no 
adequate measures have been put in force 
to cure the evil or arrest its progress. 

It is very evident that the profession, 


and the public generally, are not awake 
to their responsibility in this matter, for 
if they were, the conditions would soon 
be changed. The introduction of vacci- 
nation against small-pox has almost 
driven the disease from the face of the 
civilized portions of the earth. Great 
efforts are being made to stamp out the 
scourge of tuberculosis. Much has been 
done to prevent cholera, diphtheria, teta- 
nus, rabies, yellow fever, typhoid fever, 
cerebrospinal meningitis, etc., but practi- 
cally nothing has been done to rescue the 
95 per cent, of the school-children from 
the dangers of oral sepsis. 


The writer first became interested in 
this subject in the summer of 1878 
through a very interesting case referred 
to him by a lay friend. The conditions 
presented by the patient were so grave 
and the results of the treatment so satis- 
factory that it made a deep impression 
upon his mind. 

The relationship existing between the 
oral conditions and the general health 
was not known, — only suspected, — but 

8 113 


upon the suspicion that there was an in- 
timate relationship existing between them, 
treatment was undertaken, more, how- 
ever, as a general cosmetic and sanitary 
matter than from any real expectation 
that the general health would be improved, 
but with the hope that a clean and healthy 
mouth might mitigate some of the more 
distressing local symptoms. 

Case I. — History. — Miss S., American, 
public-school teacher, aged 40, reported, 
complaining of loss of appetite, a bad 
taste in the mouth, an excessive flow of 
saliva, causing frequent swallowing, pain 
in stomach after eating, with considerable 
flatulency, and a burning sensation in the 
stomach when empty, nausea in the morn- 
ing but no vomiting. Every afternoon 
felt feverish, languid, and tired. Had 
frequent attacks of constipation and 
diarrhoea and accumulations of much gas 
in the intestines which caused discomfort 
and embarrassment. Had decreased con- 
siderably in weight, but could not say how 
much. Complexion pale and muddy. 
Pulse normal, with no evidences of fever. 
Mental condition not good; was melan- 
cholic and dejected; had lost interest in 



her work, and did not expect to live very 

Mouth in a very dirty, unsanitary con- 
dition. Teeth had not been brushed for 
many weeks, on account of causing bleed- 
ing of the gums. Food debris covered 
all the teeth. Thick coating of salivary 
calculus over the superior molars and upon 
the lingual surfaces of the lower incisors, 
cuspids, and bicuspids; rings of salivary 
calculus at the margins of the gums upon 
all the other teeth ; gums swollen, red and 
ulcerated at the margins and festoons; 
pressure upon the gums caused bloody 
pus to well up around the lower anterior 
teeth and the superior molars. Mucous 
membrane of the mouth red and in- 
inflamed. Had frequent attacks of ton- 
sillitis. Teeth showed little evidences of 
dental decay. No teeth had been lost. 

Treatment. — The treatment consisted 
in a thorough cleansing of the mouth and 
teeth and the removal of salivary cal- 
culus, painting the gums with the tincture 
of aconite and iodine, equal parts, after 
each treatment. The cleansing of the 
mouth and teeth occupied several sittings 
of an hour each, extending over a period 



of three weeks, with semi-weekly visits 
for a period of three months, for treat- 
ment of the gums, the filling of a few 
cavities of decay, and to see that the 
patient was not neglecting her instruc- 
tions as to mouth cleanliness. The re- 
sults of oral cleanliness in this case ap- 
peared to the writer at the time as little 
short of marvellous, because so unex- 
pected. Her physical condition began to 
show marked improvement at the end of 
the first month. The bad taste in the 
mouth had disappeared, the excessive flow 
of saliva ceased, the appetite returned, 
the morning nausea was much lessened, 
and the discharges about the teeth had 

From this time on, there was rapid im- 
provement in all the other symptoms. 
The pain in the stomach after eating grad- 
ually lessened and finally disappeared, 
and with this the flatulency. The bowel 
symptoms, with the constipation, diar- 
rhoea, and gas accumulations were the last 
of the general symptoms to disappear. 
From the first she began to lay on flesh, 
her color became healthful, her natural 
good spirits returned, and interest in her 



work revived. In fact she was a well 
woman in less than three months after her 
mouth and teeth had been put in sanitary 

Case II. — During the following winter 
another very interesting case came into 
my hands through the courtesy of a medi- 
cal friend. 

History. — Mrs. R. S., — Hebrew, aged 
50 years, very pale and anaemic. Com- 
plained of loss of appetite, a very sore 
and sensitive mouth, tonsils and pharynx 
very red and inflamed, and had constant 
hacking cough; saliva thick and ropy; 
could not sleep when lying down; 
was exceedingly nervous, irritable in dis- 
position, and greatly depressed. Had 
one tooth that had given great trouble — the 
upper left cuspid — face had frequently 
been swollen and pus discharged into the 
mouth. The physician had sent her to 
the writer for the extraction of this tooth. 
Examination of the mouth revealed the 
most astounding oral condition that had 
ever come under the notice of the writer 
up to that time. The troublesome tooth 
was the least grave of the conditions 
found to exist. 



The patient had in her mouth a partial 
denture made on a silver base, that only 
partially covered the roof of the mouth, 
and containing eight teeth, to replace the 
superior right and left lateral incisors and 
the right and left first and second bicus- 
pids and first molars, and held in position 
by clasps fitted to the cuspid and second 
molar teeth. Before attempting an ex- 
amination preparatory to removing the 
tooth, the patient was requested to take 
out her plate. She said she could not, 
that it was put in by her New York 
dentist fifteen years ago, and that it had 
never been out of her mouth since; that 
it had grown (?) fast and that it was im- 
possible to remove it. Examination of 
her mouth revealed the fact that it was 
impossible for her to remove the plate, 
for it was firmly cemented in position by 
accumulations of salivary calculus, which 
covered the teeth on each side from and 
including the third molars, forward to the 
first bicuspids attached to the silver plate. 
The mouth was in a very unclean state, 
the lower teeth in a filthy condition from 
the remains of food debris. The gums and 
the roof of the mouth were red and 



swollen, and the plate embedded in the 
mucous membrane of the roof of the 
mouth. The plate was oxidized upon the 
exposed surface to a jet-black color. 
Pressure on the plate caused pain beneath 
it. Evidently the irritation from the em- 
bedded plate was very considerable. 

The writer's experience with Case I 
led him to suggest to the patient that her 
ill health and nervous condition was due 
largely, if not altogether, to the diseased 
condition of her mouth, and that nothing 
could be done in the way of treatment 
until the plate was removed and the mouth 
and teeth thoroughly cleansed. Upon 
consultation with her physician, the case 
was placed in the writer's hands for such 
treatment as he might think best, as she 
had been under his care off and on for 
several years with only temporary benefit. 

An appointment was made for the next 
day, when, after an hour of tedious and 
painstaking labor with chisels and excava- 
tors, the calculus was cut away and the 
plate removed. 

The under surface — that in contact with 
the roof of the mouth — of the plate was 
not discolored, in fact it looked as if it 



had just come out of the acid-bath, all 
other portions were jet black, showing 
oxidation. The soft tissue upon which 
the plate rested was covered with coarse 
granulations, which gave an acid reaction 
to litmus paper. There was considerable 
recession of the gums around all the teeth 
with which the plate was in contact, and 
all were more or less loose and discharg- 
ing a greenish pus. 

The mouth was then carefully washed 
with a solution of phenol sodique, one 
teaspoonful to a glass of water, and the 
troublesome tooth extracted; the patient 
dismissed with instructions to rinse the 
mouth with a similar weak solution of 
phenol sodique every two hours during 
the day and to return for further treat- 
ment in two days. At the next sitting 
she reported herself as much more com- 
fortable ; the mouth less sore and the saliva 
less ropy; did not cough so much last 
night. This was encouraging; so pro- 
ceeded to remove the salivary deposits 
from the lower teeth. The roof of the 
mouth was still very tender and sensitive. 
Recommended liquid diet for a few days, 
or until the mouth had healed, and fre- 


quent rinsing of the mouth and gargling 
of the throat with the phenol sodique 
solution. Instructed to report every 
second day. 

At the third visit the surfaces of all 
the teeth were examined for unremoved 
deposits and carefully polished. The 
mouth conditions have greatly improved; 
roof of the mouth healing rapidly, ropy 
condition of the saliva is much less, cough 
greatly improved, tonsils and pharynx 
less inflamed, can lie down and sleep with 
little disturbance from the cough; has a 
little appetite. Recommended that she 
take soft food — soft-boiled eggs, milk 
toast, mashed vegetables, etc. 

Fourth visit. Mouth has healed, and 
the taking of food is no longer painful; 
ropy condition of the saliva has entirely 
disappeared; seems to be normal; sleeps 
well; cough is much better; appetite good. 
Recommended full diet. Says she feels 
better than she has for months. Gave her 
specific instructions as to the care of the 
mouth, and further explained the neces- 
sity of great diligence upon her part to 
keep the mouth free from all foreign 
substances that could in any way cause ir- 


ritation and inflammation of the tissues. 

The case steadily improved day by day, 
and at the end of three months was dis- 
charged cured, greatly to her delight and 
that of her friends and her physician. 

Many more or less similar cases from 
the early experience of the writer could be 
introduced to prove the unhealthy and 
dangerous effects of a septic mouth, but 
these are sufficient for the present pur- 
pose. The writer is free to admit, how- 
ever, that at this period in his professional 
life, he was groping in the dark for some 
real, tangible, scientific explanation of 
how a dirty, unsanitary mouth could pro- 
duce such grave general symptoms, and, 
although he was familiar with the " germ 
theory " of disease, it was not until the 
publication of Sir Joseph Lister's ideas 
of sepsis and antisepsis in relation to 
surgical wounds and diseases, that he be- 
gun to appreciate the relationship that 
might exist between them. But a full 
realization of this relationship was not ob- 
tained until the publication of Prof. W. 
D. Miller's work on " The [Micro-organ- 
isms of the Human Mouth and the Local 
and General Diseases which are Caused by 


them." To this work of Prof. Miller the 
profession and the world owe much, 
very much, for he not only searched 
out and published to the world the 
causes which produce the decay of the 
teeth, but also proved that an unsani- 
tary mouth is the habitat of numerous 
pathogenic bacteria which grow and 
multiply at a tremendous rate and are a 
source of constant infection and reinfec- 
tion of other organs and tissues of the 
body, and constitute through their ever- 
constant presence one of the greatest 
dangers to the health of which sanitary 
and medical science has any knowledge. 
In the light of our present knowledge 
in relation to sepsis and the spread of 
disease by infection, the etiology of the 
two cases just referred to is readily under- 
stood. In both cases the origin of the dis- 
eased condition was the unhygienic and 
unsanitary condition of the mouth and 
teeth: in the first, resulting in a septic 
gastro-enteritis ; and in the latter, septic 
inflammation of the fauces, an irritative 
cough due to this inflammatory condition, 
and the thick ropy saliva and a general 
neurasthenic condition from the constant 



irritation of the artificial denture and sep- 
tic intoxication. 

To Dr. William Hunter, of London 
Fever Hospital, belongs the credit of 
arousing the profession to a realizing 
sense of the great dangers to the individ- 
ual and public health from oral sepsis by 
the publication (in the Practitioner for 
December, 1900) of his researches and 
personal experiences upon this subject. 
In his introduction he says: "For the last 
twelve years, in connection with various 
studies, my attention has been called in 
increasing degree to an important and 
prevalent source of disease, one whose im- 
portance, I think, is not sufficiently rec- 
ognized. The source is oral sepsis — sepsis 
arising in connection with diseased condi- 
tions of the mouth. My attention was 
first drawn to it in connection with the 
pathology of ansemia; and since then it 
has been extended in connection with the 
pathology of a great number of infective 
diseases which have one factor in com- 
mon — namely, septic organisms under- 
lying them. 

" The case which brought to a head my 
interest in this subject was one I met with 



some two years ago. It definitely proved 
the connection between oral sepsis and 
one of its commonest effects — one so 
marked and so common that I have desig- 
nated it by a special name, septic gastritis. 
Since then I have seen a large number 
of cases, illustrating both the frequency 
and the importance of the subject; illus- 
trating, moreover, what I regard as more 
striking — the extraordinary degree to 
which oral sepsis is overlooked, alike by 
all parties concerned — the physician, the 
surgeon, the patient. 

" I have already had occasion to draw 
attention to the subject; but additional 
experience only serves more and more 
to emphasize its importance from medical, 
surgical, and preventive medicine points 
of view. 

" I desire here to point out once more 
how common a cause of disease it is, how 
grave are its effects, how constantly it is 
overlooked, and what remarkable bene- 
ficial results can be got from its removal. 
In so doing it is not my purpose to select 
rare, isolated cases from the literature in 
order to produce a picture which may 
arrest attention from its dark colors. I 



shall illustrate the subject by cases from 
my own experience, thereby bringing out 
how common the condition is." The in- 
terested reader is referred to this article. 
During the last decade much interest 
has been manifested in this subject by 
certain members of the profession, and 
much interesting material has been added 
to the literature of the subject, particu- 
larly in relation to its prevalence and a 
more general recognition of its potency 
as a factor in spreading infectious diseases. 
And yet there are many, very many, 
professional people who do not realize the 
importance of controlling or eradicating 
from our midst the great evil of an un- 
hygienic, unsanitary, septic mouth. The 
condition is so common, even among other- 
wise cleanly persons, that it is overlooked, 
or, through colossal ignorance of its 
dangers to the health of the individual 
and the public, thought to be not worth 
serious consideration. The interdiction 
by law of spitting in any street-cars, rail- 
road coach, halls of public assembly, and 
upon the side-walks will do much to pre- 
vent the spread of infectious diseases. 
But this is a measure aimed primarily 



at the prevention of the spread of tubercu- 
is, and did not at the time take into 
account the dangers of the dissemination 
of various diseases by the organisms 
found in a septic oral cavity ; and yet some 
of the pathogenic organisms found in the 
mouth are nearly as virulent as is the 
tubercule bacillus. 

The spread of such infectious diseases 
as diphtheria, tonsillitis, pharyngitis, in- 
fluenza, bronchitis, pneumonia, and pul- 
monary tuberculosis among the children 
of the public schools is, without doubt, 
crreatlv augmented bv the usual unsani- 
tan* condition of the mouths of a great 
majority of the children. 

The fight that is being made against 
the spread of tuberculosis meets with 
many physical barriers that are difficult 
to overcome. Not so with oral sepsis; 
the only obstacles in the way of a com- 
plete revolution in this matter are indiffer- 
ence, prejudice, and ignorance. 




The toxic nature or poisonous prop- 
erty of human saliva is a well-known fact, 
the knowledge of which dates back to the 
earliest days of medicine. 

Galen, Aristotle, Pliny, and other an- 
cient writers speak of its poisonous effects 
upon animals. Aristotle mentions a girl 
whose bite was as poisonous as that of 
a venomous snake, and that animals 
wounded with arrows dipped in her saliva 
died from its effects. There is also a 
popular impression that the human saliva 
is most virulent or poisonous during anger 
or nervous excitement. 

Pasteur (1881) discovered the poison- 
ous nature of human saliva to depend 
upon a group of mouth micro-organisms, 
including the micrococcus of sputum 
septicaemia. Miller looks upon this 
organism as one of the most important 
of all the mouth bacteria, as it is very 
virulent and is the same organism that 



produces lobar pneumonia — the pneumo- 
coccus — and doubtless the direct cause of 
this disease. Injections of cultures of this 
organism killed rabbits in from twenty- 
four to thirty-six hours. The bacteria 
of the human mouth are very numerous, 
as shown by the investigations of Miller, 
Black, Robin, Goadby, Vicentini, and 
other investigators. Considerably over a 
hundred different species have been dis- 
covered at various times and under vary- 
ing conditions. About one-third of these 
are known to be pathogenic — disease-pro- 
ducing — germs, some of which have prop- 
erties of great virulence, for instance, the 
micrococcus of sputum septicaemia just 
referred to and the bacillus pulpas gangre- 
nosa? — the organism found in a decompos- 
ing tooth-pulp — which is the most virulent 
of all and is the common cause of acute 
dento-alveolar abscess. 

The pyogenic — pus-producing — organ- 
isms are found everywhere: in the air, in 
water, in the soil, in the dust of the streets ; 
upon the surfaces of the human body, par- 
ticularly in the epidermal covering of the 
skin, in the folds of the skin, at locations 
where the sweat glands are most numer- 

9 129 


ous — under the arm, etc.; in the hair, 
under the finger nails, in the nasal pas- 
sages ; but most abundantly in the mouth. 

It is generally conceded that these or- 
ganisms are found in every mouth, the 
abundance being governed largely by its 
hygienic and sanitary condition. The un- 
sanitary mouth offers a most admirable 
field and soil in which they grow and 
multiply with great rapidity. 

These organisms are really omnipres- 
ent, and ready at all times to take ad- 
vantage of any opportunity offered to 
attack the tissues of the body and produce 


Prof. Miller arranges these avenues 
of infection under six heads, according to 
the point of entrance: 

" 1st. Infections caused by a break in 
the continuity of the mucous membrane, 
brought about by mechanical injuries. 
These lead to either local or general dis- 

" 2d. Infections through the medium of 
gangrenous tooth-pulps, which lead to the 



formation of abscesses at the point of in- 
fection, but may also lead to secondary 
septicaemia and pyaemia with fatal ter- 

"3d. Disturbances conditioned by the 
resorption of poisonous waste products 
formed by bacteria. 

" 4th. Pulmonary diseases caused by 
inspiration of slime — mucus — small pieces 
of tartar, etc., containing bacteria. 

" 5th. Excessive fermentative pro- 
cesses, and other complaints of the diges- 
tive tract, caused by the continual 
swallowing of microbes and their poison- 
ous products. 

" 6th. Infections of the intact soft 
tissues of the oral and pharyngeal cavities 
whose power of resistance has been im- 
paired by debilitating diseases, mechanical 
irritations, etc. 

" In this connection the possibility of 
an infection by the accumulation of the 
excitants of diphtheria, typhus, syphilis, 
etc., in the mouth must also be taken into 

The most common avenue of infection 
by pyogenic bacteria within the mouth is 
through some break in the continuity of 



the mucous membrane. It may be only 
a slight abrasion or a minute wound such 
as might be made by the bristles of a 
hard tooth-brush, a tooth-pick, a fish-bone, 
or a too vigorous use of the floss-silk, or 
a more serious lesion such as that made 
by the extraction of a troublesome tooth, 
either of which would furnish a sufficient 
entrance or point of attack, and might 
prove exceedingly dangerous in a particu- 
larly unclean mouth, by reason of a low- 
ered vital resistance of the injured tissues 
or of the general system such as might 
follow a debilitating illness. 

That the presence of pathogenic 
bacteria in the mouth does not always re- 
sult in the production of disease is due 
in large measure to the remarkable resist- 
ant powers possessed by the mucosa of 
the mouth, to the power of the blood, 
through the phagocytes — white cells — to 
destroy the bacteria that may enter the 
system, and to the number that may gain 
an entrance or be introduced at any one 
time. This process may be looked upon 
as a desperate battle waged between two 
opposing armies; the phagocytes upon 
the one side, and the bacteria on the other, 



being assured that the strongest and most 
numerous force will conquer. How im- 
portant, then, is the conservation of the 
general health! 


The most common disease of the teeth, 
due to an unsanitary mouth, is that of 
dental decay, as already stated in a pre- 
vious chapter, and is due to the dissolving 
action of acids upon the lime salts of the 
teeth. These acids are produced by the 
action of the zymogenic — fermentative — 
bacteria upon particles of food left in the 
mouth and lodged between the teeth or in 
the pits and grooves upon their surfaces. 
This action always begins upon the outer 
surface, or enamel, of the teeth, and as 
the enamel becomes softened it is re- 
moved by the friction of mastication and 
other means, leaving a shallow cavity, 
which then offers a larger and more suit- 
able lodging-place for food and greater 
activity of the acid-producing germs. 
This process of decay usually extends 
towards the centre of the tooth, follow- 
ing the dental tubuli — microscopic tubes 
in the dentine — until the dental pulp is 



reached. The acid formed by the fermen- 
tation of the food debris acts more rapidly 
upon the dentine than upon the enamel, 
and, as the process of decalcification — 
removing of the lime salts — goes on, the 
dental tubuli are left behind as the leath- 
ery or cartilaginous substance, which is 
later gradually dissolved or liquefied 
by the saprophytic — putrefactive — germs 
and washed away. The disagreeable odor 
and taste from a decaying tooth are 
caused by the putrefaction of this cartila- 
ginous substance. This process of decay 
may become arrested through a changed 
environment, which constitutes immunity. 

One of the common results of dental 
decay is pulpitis — inflammation of the 
tooth-pulp — or toothache produced by the 
pyogenic bacteria. This is an exceedingly 
painful affection while it lasts, which 
sooner or later ends in death of the organ 
and remission of the pain. Little children 
frequentty suffer great agony from this 
form of dental disease when their teeth are 
neglected and allowed to decay. 

Den-to-alveolar A bscess — gum-boil — 
usually follows death of the pulp after an 
interval of from two to four weeks, by 



infection of the tissues at the apex of the 
root with the virulent bacillus pulpce gan- 
grenosa*. These organisms follow the canal 
in the root and set up most violent acute 
inflammation, and the formation of an 
abscess, accompanied by severe throbbing 
pain, great swelling, and elevation of tem- 
perature. This is a serious affection and 
should never be neglected, as it may re- 
sult in necrosis of the jaw or acute sep- 
ticaemia — blood-poisoning — and death. 
Many cases are on record of a fatal ter- 
mination of this disease. The abscess if 
allowed to run its course will usually, ex- 
cept in the very serious cases, point upon 
the gum and rupture — break — discharg- 
ing its contents into the mouth, when the 
more acute symptoms will subside, but 
leaving behind a chronic discharge which 
may last years unless appropriate treat- 
ment is adopted. This latter condition 
constitutes one of the most prolific sources 
of oral sepsis. 

Dento-alveolar abscesses associated with 
the upper jaw not infrequently rupture 
into the nasal fossa, simulating a chronic 
nasal catarrh, or into the maxillary sinus 
— a natural cavity in the upper jaw just 



above the bicuspid and molar teeth and 
beneath the eye — and cause what is known 
as empyema — a collection of fluid — gen- 
erally pus from the abscess which has 
discharged into it. After a time gas is 
formed in the sinus from putrefaction of 
the pent-up fluid causing distention and 
pain with protrusion of the eyeball upon 
the affected side. The walls of the sinus 
become thinned and sooner or later rup- 
ture. This usually occurs into the nose, 
as the bone at this point is least resistant. 
Occasionally it will rupture into the orbit 
and penetrate the skull, causing death by 
septic cerebral meningitis. 

Dento-alveolar abscess associated with 
the lower jaw usually ruptures upon the 
gum within the mouth, but it is by no means 
uncommon for it to penetrate the soft 
tissues of the face and discharge upon 
the chin or lower border of the jaw. 
Occasionally, as in the case of impacted 
lower third molars, the pus will burrow 
beneath the jaw and follow the spaces 
between the muscles and rupture upon 
the neck or breast. The latter is a very 
serious condition and may terminate 
fatally through general septic poisoning. 



The common results of violent acute 
dento-alveolar abscess are periostitis, os- 
titis, osteo-myelitis, abscess of the acces- 
sory sinuses, and necrosis, or death of the 
bone. These conditions are productive of 
very grave results, as they furnish, 
through the constant discharge of a very 
virulent pus, one of the most serious 
sources of auto-infection, both local and 
general, that are to be found in the oral 

The absorption of ptomaines and the 
entrance of the micro-organisms into the 
blood and lymph channels from dento- 
alveolar abscess, periostitis, osteitis, osteo- 
myelitis, and necrosis of bone are also 
productive of many serious affections in 
remote parts of the body dependent upon 
pyogenic infections and saprophytic or 
septic intoxication. 

The soft tissues of a septic oral cavity 
are very prone to take on inflammatory 
action, particularly if the teeth are badly 
decayed and salivary deposits are present 
in considerable amount, as these condi- 
tions produce more or less mechanical irri- 
tation, abrasions, and slight wounds upon 
the mucous surfaces. Such wounds per- 



mit the entrance of the pyogenic bacteria 
and set up septic inflammation and ulcera- 
tion. The gums are very liable to these 
forms of inflammation, through the me- 
chanical irritation and abrasion of the tar- 
tar found upon the teeth and encroaching 
upon the gums. The mucous coverings 
of the lips and cheeks are often injured by 
the same cause and by rough and jagged 
portions of decaying teeth, and also by 
infection of glandular structures from 
the presence of the pyogenic bacteria. 
The tongue is sometimes the seat of ulcers 
due to the mechanical irritation of decayed 
teeth and masses of tartar, and infection 
with the pyogenic bacteria, and which do 
not heal until these causes of irritation 
are removed. Ulcers of this character 
are very often, when neglected, the start- 
ing-points of cancer. The local manifes- 
tations of pyorrhoea alveolaris — namely, 
the suppurative conditions of the sockets 
of the teeth — are due to infection from 
the same pyogenic bacteria. 






Throat affections are always more 
prevalent during the winter or cold 
months and early spring than during the 
summer. The popular opinion as to the 
reason for this difference in the seasonal 
prevalence is that during the cold months 
and early spring people are more liable 
to take cold than they are in the summer 

The correct explanation, in the writer's 
opinion, lies in the fact that during the 
summer time the people are less exposed 
to infections, because they spend more 
time out of doors, and that their homes, 
the school-rooms, churches, public halls 
of assembly, street-cars, and railroad 
coaches are all wide open and well venti- 
lated, thus reducing danger of infection 
to the minimum; while during the winter 
and the inclement months of the spring 
the people largely remain in-doors, and 
their homes, places of business, and public 



resorts, including the school-rooms, the 
churches, street-cars, and railroad coaches, 
are heated to an unnecessary degree and 
badly ventilated. As a result the air in 
these buildings is foul and loaded with 
septic organisms from the mouths of 
people who pay no attention to oral clean- 
liness, or who are suffering from some 
infectious or septic oral, throat, bronchial, 
or pulmonary complaint, the germs of 
which find lodgement in the air-passages 
and the mouth of the assembled people 
and establish infections that would be 
practically impossible out of doors or in 
well-ventilated open buildings and public 

Periodic attacks of tonsillitis almost in- 
variably accompany an unsanitary, septic 
oral cavity. This has been a matter of 
such convincing observation for several 
years, upon the part of the writer, that 
he feels like saying that tonsillitis is never 
associated with a clean, hygienic mouth, 
except from direct infection through un- 
clean instruments of the oral or throat 

Pharyngitis, laryngitis, and angina 
are septic inflammations having their 



origin in a septic condition of the nasal 
or oral cavities, but most frequently from 
an unclean septic mouth, and which can be 
prevented in a large majority of instances 
by a proper attention to oral cleanliness 
and oral hygiene. 

Very much has been written during the 
last decade upon the subject of the 
"Tonsils as Portals of Infection, 33 but the 
question as to what extent these glands 
are responsible for the introduction of in- 
fectious materials into the lymph and 
blood streams is by no means settled. 
There is no doubt that under certain con- 
ditions they may become active factors 
in the absorption of toxic materials, as 
in diphtheria and scarlet fever, but no 
more so than the mucous membrane and 
lymphoid tissues of the pharynx, naso- 
pharynx, and fauces. 

Some authors lay so much stress upon 
the role played by the tonsils as gatherers 
and disseminators of infectious and toxic 
materials that they entirely overlook the 
possibility and the probability that much 
of the general infection for which the 
tonsils are blamed is due to the absorption 
of pyogenic organisms and toxins by the 



mucous membrane and lymphoid tissues 
of other portions of the throat and of the 
mouth. The tissues of a septic mouth are 
always in a more or less inflamed con- 
dition, and many times in a state of sup- 
puration and ulceration; these conditions 
being particularly favorable for the pro- 
duction of toxins and for the absorption 
of septic materials. 

With a very few exceptions no mention 
is made in these articles of the unsanitary 
mouth and the role it plays in the produc- 
tion of septic materials and as a portal 
of infection. The septic mouth is the in- 
cubator from which the tonsils most likely 
receive their infection with pyogenic 
micro-organisms and certain toxins elabo- 
rated by the saprophytic germs. 

Packard 1 is a notable exception in this 
regard, as he calls especial attention to 
the multitude of pathogenic micro-organ- 
isms found in the human mouth, and 
suggests, " With such an array of micro- 
organisms in the mouth, it seems as though 
there must be constant infection of the 
mucous membrane." 

*New York Medical Journal, June 24, 1899. 


Mayer 2 in this connection says, " The 
strictest attention to the hygiene of the 
mouth should be enjoined even after 
thorough ablation of the tonsils," thus rec- 
ognizing the possibility of infections oc- 
curring through other tissues than the 

The spreading of diphtheria is much 
more rapid and its virulence greater 
among children with neglected and septic 
mouths than among those whose mouths 
are in a fairly hygienic condition. The 
presence of the bacillus of diphtheria in 
the human mouth was first observed by 
Loffler in the mouth of a healthy child. 
These organisms have since been fre- 
quently found in the mouths of healthy 
persons and seem under such circum- 
stances to do no harm. Miller 3 thinks 
that this fact " favors the view that the 
secretions of the mouth are a suitable 
nutrient medium for the germs of diph- 
theria, and that possibly they appear in 
the mouth oftener than has heretofore 
been supposed, reserving their specific 

2 Journal American Medical Association, December, 

3 Miller's Micro-organisms of the Human Mouth, p. 387. 



action until certain favorable conditions 

The Massachusetts Associated Boards 
of Health 4 found in some recent investi- 
gations that the Klebs-Loffler bacillus was 
present in the throats of from one to two 
per cent, of all healthy persons, and in 
from eight to fifty per cent, of all those 
who had been exposed to diphtheria in 

How very important, then, becomes the 
care of the human mouth and the preser- 
vation of its tissues and secretions in a 
healthy state! Cleanliness, first, last, and 
all the time, should be the watchword, not 
only in the nursery of the well-to-do and 
the rich, but in every home in which chil- 
dren abide, particularly in the homes pro- 
vided for the indigent children of our 
great cities and commonwealths, for in 
these places neglect of oral cleanliness is 
most likely to be found. 

Albert Mills 5 found that " the micro- 
organisms 5n the saliva in general in- 
creased the virulence of imported germs." 
The fact that the virulence of the bacillus 

4 Medical Record, March 2, 1907. 

6 Ann. Roy. Soc. de Med. et Nat. de Brux., 1896. 



of diphtheria can be exalted by inocula- 
tion along with it of the streptococcus 
pyogenes — a pus organism — is very preg- 
nant with suggestion (Alderson). 

In this connection it may be proper to 
ask if the bacillus of diphtheria, of tuber- 
culosis, of cholera, and of syphilis, when 
transplanted to a septic mouth, may not 
have their virulence greatly increased by 
growth in such an environment? 

Pommay 6 says, " Virulence is not a 
primitive original, and necessary condi- 
tion of pathogenic microbes; it is an ac- 
quired, contingent condition, which pro- 
ceeds from the evolution of certain 
microbes in certain conditions and soils. 
Of culture media some increase or create 
the virulence; others attenuate or ex- 
tinguish it; others are indifferent — that 
is, neither modify nor produce it." 

Ellegood 7 is of the opinion that " The 
life processes of some of the bacteria 
always found in the mouth appear at 
times harmless, and at others malignant, 
in the sense of being inimical to the 
healthv conditions of the tissues. The vital 

6 Vicentini's Bacteria of the Sputum, etc., p. 153. 

7 Laryngology, 1906, p. 270. 

10 145 


phenomena of some of this class, how- 
ever, as well as of numerous species whose 
occurrence in the mouth is purely 
accidental, are under certain circum- 
stances distinctly pathogenic." 

Dr. Ackerly, 8 of London, says, " I am 
convinced, after holding a post as medical 
officer to an isolation hospital for many 
years, that the severity of throat symp- 
toms in diphtheria and scarlet fever, and 
of the severity of an attack of enteric 
fever, depends largely upon the presence 
or absence of oral sepsis; and in such a 
disease as appendicitis there is much 
reason to believe that oral sepsis has much 
to do with the more severe cases in which 
a catarrhal affection rapidly becomes a 
purulent inflammation. The extraordi- 
narily rapid improvement which takes 
place in the dyspepsias and other troubles 
of the people when there is only slight 
sepsis when this is attended to, by itself 
justifies such attention and makes delay 

He says, further, 9 ' When patients 
admitted with diphtheria had clean mouths 

8 British Journal Dental Science, July, 1910, p. 586. 

9 British Journal Dental Science, July, 1910, p. 599. 



and good teeth, the pathologist reported 
that cultivations from the throat showed 
a pure or almost pure culture of the diph- 
theria bacillus; but when the mouth was 
dirty, the culture showed a mixed in- 
fection and the type of disease was severe. 
In cases of typhoid, too, it made an enor- 
mous difference whether the mouth was 
clean or dirty, on the course of the 

Diseases of the ear of septic origin 
are frequently associated with an unclean 
and septic oral cavity, particularly those 
conditions which are dependent upon the 
staphylococci, streptococci, and the pneu- 
mococci as sources of infection. The 
nasal passages are almost never free from 
these organisms, and it is quite probable 
that many middle-ear affections are due 
to the presence of these organisms located 
primarily in these passages. The oral 
cavity is, however, never free from septic 
organisms, and when it is in a neglected, 
unsanitary condition, it is a veritable hot- 
bed of infection, swarming with myriads 
of septic organisms which infect the 
tonsils, the pharynx, the nasopharynx, the 
larynx, the trachea, the bronchial tubes, 



the lungs, the stomach, and the intestines. 

The micro-organisms of a septic oral 
cavity travel from the mouth to the ton- 
sils and pharynx, from the pharynx to 
the nasopharynx, from the nasopharynx 
to the Eustachian tubes, and thus reach 
the middle ear. It is possible also for the 
pyogenic organisms in the mouth to reach 
the tissues of the middle ear through the 
blood and lymph streams. 

In this connection the history of the 
following case will be of interest: Mrs. 
G., the mother of a medical friend, had 
for sixteen years been troubled with an 
offensive discharge from the left nostril. 
Prior to this she had suffered intensely 
from pain and swelling in the region of 
the left maxillary sinus, which lasted for 
several weeks and then subsided. This 
condition was accompanied by a profuse 
discharge of offensive secretions from the 
left nostril. Later the swelling dis- 
appeared, but the discharge never wholly 
ceased. Six years after the first attack, 
the face again became very painful and 
much swollen, this time extending far- 
ther back, finally developing what was 
thought to be abscess of the middle ear, 



Large quantities of pus were discharged 
from the ear through the external meatus, 
and at one time it was feared that the 
suppurative process would extend to the 
meninges of the brain. After several 
weeks of intense suffering the symptoms 
subsided and finally the discharge from 
the ear entirely ceased. After this, how- 
ever, the discharge from the left nostril 
seemed to be increased and the symptoms 
were always aggravated by taking cold. 
The teeth upon the left side of the upper 
jaw had all been extracted one by one 
as a possible cause of the trouble, except 
the third molar, which had never erupted. 
This procedure, however, produced no 
abatement of the symptoms. Later the 
teeth of the opposite side were removed 
for the purpose of inserting a complete 
upper artificial denture. About ten years 
after the last-mentioned attack, while 
leaning over a wash-bowl, brushing her 
teeth, she suddenly noticed that the left 
nostril was plugged up by some movable 
body. On throwing the head backward 
in an attempt to dislodge it, the mass fell 
into the fauces, and was ejected from the 
mouth into the bowl. Upon examination, 



it proved to be a well-developed left supe- 
rior third molar, more or less covered with 
hard concretions of a dark-brown color. 
The discharge from the nose from this 
time on grew gradually less, and finally, 
after a few months, ceased altogether. 

The probable explanation of the pecu- 
liar features of this case are, briefly : first, 
the third molar was developed in an in- 
verted position, and very near to the floor 
of the maxillary sinus. Second, suppura- 
tive inflammation was established in the 
crypt of the tooth germ from irritation 
induced by its development in an ab- 
normal position and the lodgement and 
multiplication of pyogenic organisms 
floating in the blood or lymph streams. 
Third, the pus cavity ruptured into the 
maxillary sinus. Fourth, the abscess of 
the middle ear may have been an exten- 
sion of the tooth abscess, though there 
is some doubt as to this, as the anatomy 
of the parts does not readily favor such a 
supposition. The more probable explana- 
tion of the otitis media is that of infection 
through the blood and lymph streams. 
The tooth probably became lodged against 
the nasal wall of the sinus, causing ul- 



ceration and destruction of bone, which 
finally permitted it to pass into the nasal 
cavity, and this be expelled. 

Inflation of the Eustachian tubes in the 
presence of a septic oral cavity with almost 
certain infection of the nasopharynx by 
extension, is a dangerous procedure, and 
should never be undertaken until the 
dangers of a virulent infection have been 
removed by proper treatment of the septic 
condition of the mouth. 

Pain in the ears is a frequent accom- 
paniment of dental diseases, particularly 
of acute pulpitis, pericemental irritation, 
difficult eruption of individual teeth, and 
impaction of the third molars. Little 
children frequently suffer during denti- 
tion from reflex pain in the ears — 
otalgia — due to pressure upon the gingi- 
val nerves during the eruption of the 
teeth, particularly the molars. 

In adults the otalgia is most frequently 
associated with an acute pulpitis or an 
acute pericementitis. These conditions 
present no difficulties in diagnosis to the 
dental surgeon or the otologist, and 
appropriate dental treatment gives im- 
mediate relief; but the more rare con- 



dition of aural pain dependent upon the 
irritation of an impacted third molar 
often presents most perplexing symptoms. 
The most critical examination of the ear 
may give absolutely negative results, 
while a most thorough examination of the 
mouth and teeth may give no enlighten- 
ment upon the cause, except perhaps the 
absence of a third molar upon the affected 
side. Under such circumstances the 
Roentgen ray will decide the question of 
the presence or absence of the missing 
tooth and its position if present. Many 
times, however, the presence of the tooth 
is easily demonstrated by the aid of a fine 
steel probe, as usually a small opening 
can be found in the gum close to the 
posterior surface of the second molar, 
that leads to the crown of the trouble- 
some tooth. Cases of this character call 
for operation at the hands of an expert 
oral surgeon. The removal of the tooth 
usually cures the otalgia. 

Diseases of the eye associated with 
septic conditions of the oral cavity may 
arise in three ways: First, by direct ex- 
tension of disease, as in a case of purulent 
empyema of the maxillary sinus ruptur- 



ing into the orbit, or by cellulitis of the 
cheek, or an osteomyelitis of the upper 
jaw, caused by dento-alveolar abscess, or 
by the migration of septic organisms from 
the mouth through the nasal passages and 
into the lachrymal canal and then into 
the conjunctival sac. Second, by the 
passage of septic organisms into the blood 
and lymph streams and the establishment 
in the optic tissues of metastatic foci of 
infection. Third, by reflex irritation 
through the fifth nerve, due to dental 
caries, hyperemia of the pulp, interstitial 
calcification of the pulp — pulp stones — 
acute and chronic pulpitis, acute and 
chronic pericementitis, pressure upon the 
gingival nerves in tooth eruption, im- 
pacted third molars, crowding of the teeth, 
as in cases of irregularities, where the 
jaw is too small for the teeth, and in the 
too rapid movement of the teeth by 
orthodontia appliances. 

Cases of suppurative inflammation in- 
volving the orbit and the tissues of the 
eye, by extension from diseased teeth, such 
as cellitis of the cheek, purulent em- 
pyema of the maxillary sinus, and osteo- 
myelitis of the upper maxilla, are exceed- 



ingly dangerous, as they may oause loss 
of the eye, or the infection may extend 
to the cranial cavity and cause death by 
septic inflammation of the meninges of 
the brain. Fortunately, diseases of this 
character are not at all frequent. 

Diseases due to reflex irritation are 
much more common and numerous, but 
it is sometimes very difficult to establish 
a positive diagnosis. Many times this can 
be done only by a process of exclusion. 
This arises in some instances from the un- 
certainty as to the point at which the re- 
flex pain may be expressed. It has been 
learned from observation that in hip- joint 
disease the pain is usually expressed at 
the inner side of the knee, that in iritis 
the pain is usually located in the eyebrow, 
while in cancer of the larynx it is expressed 
in the ear. A dental pulpitis may cause 
pain in the ear or the side of the face, or 
in the parotid gland, or in the eye, causing 
a profuse lachrymation. On the other 
hand, diseases of the eye have been known 
to cause reflex pain in the teeth. 10 

Among the diseases of the eye which 
have been traced to dental irritation are 

10 Galezomsky, Journal d'ophth., 1872. 


iritis, conjunctivitis, kerato-scleritis, optic 
neuritis, herpetic eruption upon the cor- 
nea, strabismus, amblyopia, glaucoma, 
amaurosis, ptosis, paralysis of accommo- 
dation, spasms of the muscles of the lids, 
and paresis. 

An interesting case of amaurosis de- 
pendent upon dental irritation was pub- 
lished in the Journal of the American 
Medical Association, volume i, page 637. 

History. — The patient, Mrs. L., 34 
years of age, in fairly good health, was 
seized with severe pain in the left eye 
and great soreness in the left superior 
bicuspid tooth which had been filled about 
two years before. She had suffered for 
some little time a serious difficulty with the 
left eye, involving partial loss of sight, pro- 
fuse lachrymal discharge, and severe par- 
oxysmal pain. She stated that for several 
weeks after the tooth was plugged there 
was slight uneasiness in the tooth, with 
sensitiveness upon sudden changes of tem- 
perature, such as were produced by taking 
hot or cold drinks into the mouth, but 
nothing so marked as to require, in her 
judgment, any attention, and these symp- 
toms finally passed away. In about six 



months after the operation upon the tooth 
she begun to experience pain in the left 
eye, of intermittent character, increased 
flow of tears, and some slight obstruction 
of sight. Consulted an eminent specialist 
in New York, who, after careful examina- 
tion of the eye, could find no local cause 
for the difficulty and prescribed con- 
stitutional treatment. There being no 
improvement after several weeks, con- 
sulted him again, with the same results. 
On returning to Chicago, she consulted 
a leading ophthalmologist, who could find 
no local cause for the difficulty and 
thought it must be systemic. The symp- 
toms had for months gradually grown 
worse, so that she had been obliged to 
give up reading and writing, as all such 
efforts aggravated the symptoms. In 
this condition she again visited the New 
York ophthalmologist. After a third 
careful and most painstaking examina- 
tion, he said he could find no sufficient 
local cause for the symptoms complained 
of, and that he could do nothing for her 
except what might be hoped for through 
constitutional treatment. The history of 
the case being so remarkable, Dr. Allport 



decided to ascertain the condition of the 
pulp of the tooth referred to. On ex- 
cavating the cavity he found the bulbous 
portion of the pulp cavity filled with 
secondary dentine quite up to a line 
corresponding to the line of the alveolus. 
Above this the pulp was in a state of low 
inflammation. As the instrument pierced 
the pulp, the sensation was communicated 
to the eye, causing a paroxysm of pain. 
The previous removal of the filling had 
given some relief from pain in the eye 
and the soreness of the tooth had been 
considerably relieved. Af ter removing 
the pulp, which he did at once, and treat- 
ing the tooth for a few days, the pulp 
canal and the cavity of decay were filled. 
The case began to improve at once, and 
in a few weeks the sight was restored to 
its normal condition and all the other 
symptoms had passed away. 

The periodical literature upon diseases 
of the eye due to dental irritation of vari- 
ous forms is quite voluminous, particu- 
larly upon irritation from dental caries, 
pulpitis both acute and chronic, and sep- 
tic conditions of the pulp canals and roots 
of the teeth. 



Infection of the Cervical Glands. — 
Inflammation and enlargement of the 
cervical glands is a frequent accompani- 
ment of a septic oral cavity, especially 
with suppurative conditions of the teeth, 
like dento-alveolar abscess and pyorrhoea 
alveolaris, and of suppurative and ulcera- 
tive conditions of the gums and oral mu- 
cous membrane, as in gingivitis and 
stomatitis. The mouth is a veritable in- 
cubator for the growth of septic organisms 
which sooner or later find their way into 
the submaxillary and cervical glands 
through the lymph channels and set up 
inflammation, thus preparing the way for 
that arch-enemy of mankind, the tuber- 
cule bacillus. This enemy is always 
arrayed at the portals of the citadel, armed 
and equipped and ever watchful to take 
advantage of any mistake in strategy or 
weakness in the defence. The almost con- 
stant presence of the bacillus tuberculosis 
in the mouth renders it certain that much 
of the glandular involvement of this re- 
gion comes from or through an infection 
from the mouth. 

Neglect of the mouth and teeth of chil- 
dren is one of the chief causes of septic 



and tubercular abscess of the cervical 
lymphatic glands, and prepares the way 
for a general invasion of the tubercle ba- 
cillus and the establishment of tubercular 
bone diseases, pulmonary tuberculosis, etc. 

Tuberculosis enters the system by three 
avenues : 

1st. By the lungs, through direct in- 
halation of the specific organism in dried 

2d. By the lymphatic glands of the in- 
testines, through the presence of the or- 
ganisms in foods and drinks. 

.3d. By the lymphatic tissue of the 
mouth and throat, through the constant 
presence of these organisms in the mouth. 
(Sims Woodhead.) 

The most common causes of the en- 
largement of the submaxillary and cervi- 
cal glands are infections from devitalized 
teeth containing gangrenous and putre- 
fying pulps, chronic dento-alveolar ab- 
scesses, chronic suppurative gingivitis, 
ulcerative stomatitis, and pyorrhoea al- 
veolaris. Chronic affections are much 
more liable to produce glandular enlarge- 
ments and suppurative inflammations 
than are acute affections, like acute dento- 



alveolar abscess, acute gingivitis, or an 
acute stomatitis. Many, very many, cases 
of glandular enlargement located in the 
submaxillary and cervical regions have 
been referred to the writer for diagnosis 
and treatment, and in almost every in- 
stance a suppurating lesion has been found 
in the mouth, — most often a diseased 
tooth, the treatment of which from the 
aseptic stand-point or its extraction has 
been sufficient to cure the glandular en- 
largement. In a very few instances the 
mouth has shown no evidences of a sup- 
purative lesion. In these cases inquiry 
has sometimes elicited the fact of a recent 
attack of tonsillitis which explained the 
glandular enlargement. 

Many delicate children, who are poorly 
nourished, with perverted appetites, pale 
and pasty complexions, peevish and fret- 
ful in disposition, dull in mind, acutely sus- 
ceptible to changes in temperature and hu- 
midity, and with enlarged submaxillary or 
cervical glands, are sufferers from chronic 
toxaemia due to an unsanitary and septic 
mouth. The placing of the mouth of such 
a child in a hygienic condition will in a 
few weeks produce a marvellous change 



in body and mind, and will convince the 
most skeptical of the value of a clean and 
healthy mouth as a factor in the general 
health of the body and mind. Did the 
size of this little volume permit, numerous 
instances from the practice of the writer 
might be cited in proof of this statement. 
Cases of this character are so numerous 
that there should be no trouble in 

11 161 


diseases of the stomach, intestines, 

and other viscera caused 

by oral sepsis. 

Diseases of the stomach and intes- 
tines associated with faults in digestion 
are usually attributed to catarrhal affec- 
tions, induced by indiscretions in eating 
and drinking, overwork, worry, sedentary 
habits, lack of exercise, mental shock, 
general ill health, improper mastication or 
insufficient mastication due to painful 
teeth, decayed teeth, or loss of teeth. 
In view of our knowledge, however, 
of the enormous number of micro-organ- 
isms growing in a septic oral cavity, and 
of the fact that a considerable propor- 
tion of them are pathogenic in char- 
acter and sometimes of great virulence, 
sepsis as a cause must be added to the 
above list. 

The long-continued ingestion of myri- 
ads of septic and fermentative bacteria, 
during the preparation of the food by 
mastication and insalivation for the pro- 
cess of digestion, and during the intervals 



between the taking of food, cannot but 
prove detrimental and positively harmful 
to the process of digestion and to the integ- 
rity of the gastric and intestinal mucous 
membrane and their glandular structures. 
AVe wonder sometimes why glandular infec- 
tions of these tissues are not more com- 
mon and why the results of these infec- 
tions are not more disastrous to the health 
and general welfare of the human body 
than they are. This is partially explained 
by the fact that the human saliva has 
under certain circumstances an inhibitive 
effect upon the grow r th and virulence of 
these organisms ; and that under other cir- 
cumstances they accelerate their growth 
and increase their virulence. Further- 
more there are periods in the life of the 
individual when the susceptibility to dis- 
eases is of greater or less degree than at 
other times, or there may be complete 
immunity established. 

It is true also that the free hydrochloric 
acid of the gastric juice will destroy the 
vitality of many of the germs entering 
the stomach and thus protect itself against 
their irritating and septic effects. There 
are certain organisms, however, — such as 



the tubercule bacillus, that is enclosed in 
a protecting envelope or capsule, — that 
may pass through the stomach and intes- 
tines entirely unharmed. 

Ordinarily the growth of the putrefac- 
tive and zymogenic — fermentative — or- 
ganisms is inhibited in the gastric juice, 
but when this fluid is weak in hydrochloric 
acid (HC1) or when the number of the 
ingested germs is so great as to over- 
whelm the corrective action of the acid, 
putrefaction and fermentation are set up 
in the stomach, causing irritation and in- 
flammation of its glandular structures and 
the establishment of a condition of gastric 
catarrh, chronic indigestion, or dyspepsia. 

If, on the other hand, the mouth is the 
seat of suppurative conditions such as 
certain forms of gingivitis and stomatitis, 
or suppuration associated with dento- 
alveolar abscess and pyorrhoea alveolaris, 
or with extensive dental decay and gan- 
grenous and sloughingdental pulps, which, 
as already stated, furnish the most virulent 
septic organisms, septic inflammation of 
the glandular structures of the stomach 
may be established — the septic gastritis 
of Hunter — by infection. These septic 
conditions not infrequently pass on to the 



intestines, attacking the glandular struc- 
tures and setting up an enteritis, or ap- 
pendicitis, or colitis. The infection may 
also extend to the bile and pancreatic 
ducts, setting up a cholecystitis or a 
pancreocystitis. (Probyn.) It is not at 
all improbable that many cases of gastric 
and intestinal ulcer might be traced to 
infection of the glands of the stomach and 
intestines from the virulent pus organisms 
of a septic mouth. 

Furthermore, the bronchial tubes and 
the lungs are subject to septic infection 
from an unsanitary mouth. Septic 
pneumonia is by no means an uncommon 
sequela of the administration of the gen- 
eral anaesthetics through entrance of 
particles of septic material and micro- 
organisms to the pulmonary structures 
during the stertorous breathing of nar- 
cosis. Miller ' is of the opinion, as also 
Frankel, Weichselbaum, and Baumgar- 
ten, that lobar pneumonia is in all prob- 
ability an infection from the mouth due to 
the coccus of sputum septicaemia — pneu- 

Miller quotes Isreal 2 as furnishing 

1 Micro-organisms of the Human Mouth, pp. 261, 262. 

2 Micro-organisms of the Human Mouth, p. 299. 



striking proof of the correctness of the 
supposition that pulmonary diseases may 
occur from the inspiration of pathogenic 
germs of the mouth. In a case of 
primary actinomycotic infection of the 
lungs, Isreal found a small irregular body 
resembling a piece of dentine, which he 
sent Miller for examination. It was 
found to consist of a fragment of den- 
tine — tooth bone — surrounded by a chalky 
mass, composed of phosphate and carbon- 
ate of lime, presumably tartar — salivary 
calculus. The microscope revealed nu- 
merous threads of the ray fungus — the 
organism which produces lumpy jaw in 
cattle — and there can be little doubt that 
the fragment of dentine was the carrier 
of the infection. 

Baumgarten 3 reports a similar case of 
primary actinomycosis of the lung, with 
secondary extension to the soft tissues of 
the thoracic wall, by the inspiration of 
the specific fungal elements growing in 
the lacunas of the left tonsil. 

Septic inflammation of the tonsils, of 
the pharynx, of the uvula, and of the 
larynx are all usually due to a direct in- 

3 Micro-organisms of the Human Mouth, p. 299. 


fection from the pyogenic organisms 
found in the mouth, as are also gingivitis, 
stomatitis, and the local inflammatory 
manifestations of pyorrhoea alveolaris. 

The diseases which may arise by indirect 
infection through the absorption of the 
septic mouth organisms and their entrance 
into the blood and lymph channels are 
exceedingly numerous; in fact, this pos- 
sibility covers the entire range of all the 
pyogenic diseases, the more serious of 
which are osteomyelitis, ulcerative endo- 
carditis, septic nephritis, septic empyema, 
septic meningitis, acute septicaemia, 
pysemia, erysipelas, metastatic abscesses, 
diabetes, etc. 

Dr. R. Ackerly, of London, in a recent 
lecture before the Royal Society of Medi- 
cine upon " Observations on the Condi- 
tion of the Mouth in 1000 Consecutive 
Cases of Chronic Diseases," 4 says: The 
real object of the lecture was to show the 
conditions of the teeth and oral cavity 
which prevail in those patients who are 
suffering from chronic diseases; how the 
teeth were used; and the effects of im- 
proper mastication. He says: "Before 

4 British Journal Dental Science, July, 1910, pp. 570-590. 


giving an analysis of the cases, I wish to 
say that over 90 per cent, were really 
well-to-do people. Not 2 per cent, of 
them suggested that want of means pre- 
vented them having their teeth put right, 
and the vast majority of them were going 
to a doctor or a dentist more or less 

In the table of the results presented 
he says: "I have adopted certain head- 
ings. Excellent means a mouth contain- 
ing all the teeth in a good state of pres- 
ervation, with or without all the wisdom 
teeth, with no gaps, and with only few 
stoppings. Very good would mean teeth 
with practically all grinding surfaces in- 
tact, even though many have been stopped. 
Good is applied to a mouth with the loss 
of not more than three molars altogether, 
i. e., of not more than about 25 per cent, to 
30 per cent., or teeth where the gaps, if 
large, are rilled by satisfactory artificial 
teeth. Fairly good, if the grinding sur- 
face is not diminished by more than 50 
per cent. With less than this I call them 

" In the 1000 cases observed, 9 
cases, or 0.9 per cent., are described as 



* excellent '; 22 cases, or 2.2 per cent., are 
described as 'very good'; 198 cases, or 
19.8 per cent., as ' good '; 74 cases, or 7.4 
per cent., as ' fairly good.' That is, 303, 
or 30.3 per cent., are either really good or 
fairly satisfactor3 r , and provide, taking 
not too high a standard, teeth sufficiently 
good for mastication. 

" The ' defective ' mouths numbered 
360, 36 per cent.; septic, — i. e., obviously 
septic without the minute examination 
given in a dentist's chair, — 227, or 22.7 
per cent., with 0.8 in addition marked 
septic with a query. Of these 185, or 18.5 
per cent., were both septic and defective; 
the rest — i. e.j 42 — had septic gums with 
rotten stumps covered by plates. In many 
of the septic cases there were smaller 
plates, but, as explained, I recorded plates 
only when they supply 50 per cent, of 
the teeth. 

" As regards plates 87, or 8.7 per cent., 
are described as good; 250, as plates only; 
and 20 are recorded as being definitely 
bad as plates, and are classed also as 

This, he thinks, " is rather a serious 
state of affairs considering the class of 


patients. " Had a hospital or less well-to- 
do class formed the basis of the investiga- 
tion, he " had abundant evidence that the 
septic and defective sections would be 
enormously increased." " Is it not a re- 
proach," he asks, " to us as a profession 
that more than one in three people in 
contact with medical men and dentists, 
and often in contact with men of some 
note, should be so badly equipped for so 
necessary a function as mastication? But 
that more than one in five should possess 
a foul mouth is still worse. And what 
makes it worse is that this condition is 
deliberately allowed by doctor and 

"If careful mastication is necessary 
for those whom we choose to call healthy, 
because they are in the vigor of youth 
or have no marked pathological symptoms, 
surely it is much more obviously necessary 
for those who are failing in health and 
whose nutrition is imperfect, especially in 
the large groups of chronic diseases in 
which there are marked dyspeptic symp- 
toms or faulty metabolism. This includes 
all the diseases of stomach, bowels, liver, 
pancreas, and directly or indirectly most 



cardiac complaints; the conditions de- 
scribed as gouty and rheumatic; and all 
those in which there is obesity or wasting, 
or tendency to waste. Quite apart from 
the definite evils following the swallowing 
of lumps of food, or imperfectly salivated 
food, is it not obvious in these cases that 
it is only by attention to mastication, 
whatever else we do, that we can hope 
to improve the impaired nutrition? A 
great deal of attention has been bestowed 
to the dietary of sufferers from chronic 
complaints, and it is quite common for 
patients to be supplied with a list of 
articles of food that they must, or must 
not, eat; but very rarely indeed do I find 
that they are told, as I find it is often 
necessary to tell them, ' It is far less im- 
portant what you eat than how you eat 
it.' ' This is the great principle which 
underlies the teaching of Mr. Fletcher. 

Dr. Ackerly further says: "We may 
take it as agreed that thorough mastica- 
tion is important. That being the case, 
one would expect that the medical advisers 
of the people would as far as possible 
insist upon attention to the condition of 
the teeth, the removal of defective teeth, 



especially if septic, and the correction of 
any mechanical impediment to mastica- 
tion. These are the cases usually found 
at the hospital. Many of them are cases 
of very considerable duration, having been 
under treatment for many years, often 
by several doctors, and, on the whole, the 
patients are genuinely anxious to obtain 
and follow advice which is given to them 
with any show of reason fortified by con- 
viction. They are suffering from various 
forms of dyspepsia, affections of the 
stomach and bowels, rheumatism, gout, 
so-called rheumatoid arthritis, arterio- 
sclerosis, neurasthenia, and the majority 
of them are past middle life." 

Dr. Brandon reports the following 
case: 5 "Mrs. S. J. W., aged 34 years. 
Had always enjoyed the best of health 
previous to her present trouble; was 
suffering almost continually with neu- 
ralgia (facial), also dyspepsia, and, as 
she termed it, sick-headache, nervous 
prostration, loss of sleep, irregularity of 
the bowels, etc., etc., so bad that she was 
compelled to keep her bed for days at a 
time. She had employed many physicians 
with only temporary benefit. Upon ex- 

6 Medical Record, 1883, p. 587. 


amination, could detect no constitutional 
disturbance that could be attributed as 
the cause of her trouble. But noticing 
her foul breath, requested to examine her 
teeth, which were found in bad condition, 
several rotted down, others with the gums 
falling away, and so on. Requested her 
to have the offending members removed. 
She objected, as it would hurt, and went 
to another physician for treatment, but 
finally returned, when, upon assuring her 
that it would be of great help, she con- 
sented to the operation. All the irritated 
and irritating teeth were extracted. 
When asked if I was not going to pre- 
scribe for her, informed her I was not. 
Three months later she informed me that 
she had enjoyed splendid health since the 

Wallis, of London, is of the opinion 
that oral sepsis in children has more detri- 
mental effect upon health than does im- 
proper mastication. 6 " He had considerable 
opportunity in the last few years of watch- 
ing the effects of oral sepsis in London 
County Council school-children. In cer- 
tain schools there were dental charts 

'British Journal Dental Science. July, 1910, p. 591. 


showing the weights and the average ages 
of the children, and these clearly showed 
that the children with the most septic 
mouths were not only below the average 
weight of their class, but were below 
the average intellectual status of their 
age. Those with the most highly septic 
mouths were frequently two standards 
below what they ought to be in accordance 
with their age. With regard to oral 
sepsis, it has been his plan at the hospital 
to have the patients weighed weekly after 
wholesale extractions of teeth; and, in 
spite of their being left unable to masti- 
cate their food, they progressively in- 
creased in weight, and at the end of a 
few months they had in nearly all cases 
gained several pounds. That seemed to 
show that the really serious matter was 
not so much the want of mastication, as 
the fact that they were constantly swallow- 
ing the products of decomposition and 
the micro-organisms of disease." 

Diabetes. — Mr. Peter Daniel, sur- 
geon, London, in a discussion upon a 
lecture by Dr. Ackerly on " Observa- 
tion on the Condition of the Mouth in 
1000 Consecutive Cases of Chronic Dis- 



eases," said: "Another important matter 
was the relationship of diabetes to oral 
sepsis. A septic urethra or septic skull 
was not the same thing to a patient as 
a septic intestinal canal; the latter must 
be of the greatest potency in producing 
glycosuria, which every one agreed was 
due to pancreatic disease. Since 1900 
he had seen 22 cases of complication of 
diabetes which had come into his hands 
as a surgeon, and he had never seen a 
clean-mouthed man or woman among 
them. In his opinion this disease occurred 
most frequently in the people who most 
neglected the hygiene of the mouth. In 
seeking for oral sepsis, the majority ab- 
solutely ignored the gums, crowns, and 
clasps of dentures, such data being really 
indispensable to any consideration of oral 

It has been the custom heretofore to 
look upon pyorrhoea alveolaris, which is 
almost always present in diabetes, as a 
result of the diabetic condition rather 
than a cause of this disease. There is 
no longer any doubt as to the possibility 
and the probability that oral sepsis is 
productive of septic disease of the pan- 



creas by the passage of septic organisms 
from the intestine through the pancreatic 

Toxic Neuritis. — Dr. Wm. Hunter, 
in his monograph on oral sepsis, calls " at- 
tention for the first time to a new and hith- 
erto unrecognized effect of prolonged oral 
sepsis, namely, toxic neuritis." This dis- 
covery was made during his studies of 
pernicious anaemia, in which he became 
impressed with the importance of oral 
sepsis in this disease. He found the fre- 
quent occurrence of nervous effects in 
pernicious anaemia — numbness, tingling 
in hands and feet, loss of knee-jerk, 
marked wasting of certain muscles, and 
local palsies — were exactly duplicated in 
connection with extreme cases of oral 
sepsis, apart altogether from pernicious 
anaemia. He appends the notes of three 
cases which had recently come under his 
observation. In all of the cases the ner- 
vous effects were very marked. In all 
the most intense condition of oral sepsis 
prevailed, lasting for many years, in one 
case for fourteen years, and in all the 
cases immediate improvement resulted 
from a correction of this condition. 



The question which naturally arises in 
this connection is, may not many of those 
cases of neuritis in various portions of the 
body, the etiology of which is so obscure, 
be due to toxsemia induced by a long- 
continued and intense condition of oral 
sepsis. The writer is aware that his in- 
terest in this particular subject of oral 
sepsis may lead him to over-estimate the 
possibilities and dangers associated with 
this condition, but, from the observation 
and study of the human mouth for a 
period of over forty-five years, the con- 
viction has been gradually reached that 
an unclean, unsanitary, unhygienic, septic 
mouth is the greatest menace to individual 
and public health of which he has any 
knowledge; and that the very fact that 
this condition is so common and so gen- 
erally unrecognized by the profession and 
the public generally, makes it all the more 
threatening and dangerous. 

The surgeon and the accoucheur are 
often at a loss to account for septic con- 
ditions following an operation or a de- 
livery in which apparently every precau- 
tion had been taken to prevent infection. 
Two sources of infection, however, are 

12 177 


almost never thought of, — namely, the 
mouths of the surgeon or the accoucheur, 
and their assistants present at the opera- 
tion or delivery, and the mouth of the 
patient. The mere covering of the mouth 
and nose with a piece of gauze is not a 
sufficient protection against infection of 
the seat of operation when a septic 
mouth — a sometimes horribly septic 
mouth — lies just behind it, emitting with 
every breath or every explosive act of 
speech myriads of septic organisms which 
infect the air surrounding the field of 
operation and the whole room. 

With patients suffering from septic 
conditions of the mouth, entrance of 
pyogenic organisms to the blood and 
lymphatic streams is more or less con- 
stantly taking place, thus endangering 
every operation made upon the patient 
through the presence of septic organisms 
in the blood and lymph, which lodge and 
rapidly multiply in tissues that have been 
injured by any cause whatsoever. 

No surgeon or accoucheur should ap- 
proach a patient until he has rendered 
his mouth as clean as possible by the use 
of the tooth-brush and plenty of sterile 
water, nor permit an assistant or a nurse 



to be present at an operation or an 
accouchement without having taken the 
same precautions. 

It is just as important to exclude the 
possibility of infection from the unclean 
mouths of the operators and the attend- 
ants as it is to exclude the danger of 
infection from unclean hands, towels, 
sponges, instruments, ligatures, etc. 

The careful surgeon before making a 
laparotomy will take a hot bath, shampoo 
his hair, and put on sterilized clothing, 
and require his attendants to do the same. 
Great care is exercised in scrubbing the 
hands, cleaning the finger-nails, and ren- 
dering them as sterile as possible. As 
an extra precaution, all wear sterilized 
rubber gloves, and a sterilized cap over the 
hair, and a piece of gauze over the nose 
and mouth. But how many ever take 
the same care to render the mouth clean 
before operation? Xot one in a thousand. 
How many think of the necessity of hav- 
ing the mouth of the patient cleaned 
before an operation? Xot one in a 
thousand, if the operation does not involve 
that region. 

No good surgeon or accoucheur ever 
forgets to have the field of his operation 



rendered as perfectly sterile as soap and 
water, the scrubbing brush, and antisep- 
tics will make it. Yet how many ever 
think to examine the mouth for infections 
that may endanger the success of his 
operation ? Or how many accoucheurs ever 
realize that a septic mouth may endanger 
the future health or possibly the life of 
his patient? 

The mouth and teeth of every surgical 
or lying-in patient should be examined 

and such necessary dental service ren- 


dered as will remove all danger of septic 
infection before the operation or accouche- 
ment takes place. It may not always be 
possible to accomplish this with the surgi- 
cal patients, but with the obstetrical cases 
this service can usually be rendered. If 
teeth have to be extracted, anaesthetics 
should be employed to prevent shock. 

All operations upon the stomach or 
intestines, including the appendix, should 
be preceded, when possible, by prelim- 
inary attention to the teeth and mouth. 
Sepsis of the oral cavity should be cor- 
rected before any serious or important 
operation upon the abdominal viscera is 
attempted if auto-infection is to be 






One of the marked symptoms of oral 
sepsis in children is mental inefficiency, 
and this is always associated with a more 
or less serious deficiency in the normal 
standards of health. These children are, 
as a rule, pale, listless, and under weight; 
usually complaining of headache, fre- 
quently of toothache, and are subject to 
periods of constipation and diarrhoea. 
Many of them upon a close examination 
will be found to have enlarged tonsils, or 
adenoids, or both. They are subject to 
frequent catarrhal attacks of the nasal 
passages and throat, and not infrequently 
to cough which persists all through the 
winter and spring months, thus materially 
interfering with school attendance and 
placing them in the list of backward 

Errors in nutrition and septic intoxica- 
tion are the prime causes of mental in- 
efficiency in children that are born normal. 
These errors may arise from diseases of 



the teeth and the soft tissues of the mouth, 
which make normal mastication an im- 
possibility, thus interfering with the pro- 
cesses of digestion and assimilation, and 
loading the system with the poisons of 
fermentation and putrefaction of food, 
which are constantly going on in the 
stomach and bowels under these circum- 
stances, thus preventing a proper and 
healthful nutrition and growth of the 

Similar conditions may arise from a 
septic condition of the mouth, but it would 
be difficult to find a septic mouth in which 
dental decay and inflammation of the 
gums and mucous membrane were not 
present in some of their numerous 

The adult mouth is sometimes in a very 
septic condition when few or no natural 
teeth are present, but which contains 
artificial dentures that are not kept in a 
sanitary condition. Occasionally an in- 
dividual will be found wearing artificial 
dentures which have been placed in the 
mouth over a number of decayed and 
suppurating roots of teeth, or an exten- 
sive bridge has been permanently set in 



the mouth under like conditions. A more 
dangerous proceeding than this could 
hardly be imagined. Some of the most 
serious cases of oral sepsis associated with 
neurasthenia, depression, and melancholy 
that have come under the observation of 
the writer have been due to this reprehen- 
sible practice. 

Enlarged tonsils and adenoids are also 
fruitful sources of malnutrition and re- 
tarded growth in children. Proper oxy- 
genation of the blood is just as important 
in the nutrition of the tissues and the 
growth of the body as are the carbohy- 
drates, the albuminoids, and the mineral 
constituents of food. A child with narrow 
or more or less occluded nasal passages is 
never in a healthy or robust physical 
condition. Imperfect oxygenation of 
the blood is the result of contracted 
air-passages, and this leads not only to 
imperfect physical development but to 
imperfect mental development as well. 
These children are almost always dull 
and sluggish in their mental processes, 
and occasionally give the impression of 
being mentally deficient, when really the 
trouble is due to an inefficient elimina- 



tion of the waste products in the blood 
and its proper oxygenation. 

Prof. James says, " No mental modifi- 
cation ever occurs which is not accom- 
panied or followed by a bodily change." 
It may be said with equal truth that no 
important physical change ever occurs 
without leaving its impress upon the mind. 
A crooked back often produces a crooked 

Burr says, " Disturbance in the struc- 
ture or the functions of the brain inter- 
feres with the play of emotion and the 
faculty of ideation. Serious and long- 
continued impairment of its nutrition dis- 
plays itself in settled perversions of 
thought and feeling. Injury resulting in 
cerebral concussion may cause temporary 
or permanent suspension of intellection, 
and defects in cerebral development are 
accompanied by partial or complete ab- 
sence of the higher psychical processes. 
A child is born into the world the structure 
of whose brain is anatomically deficient 
or the growth of which is impeded by 
mechanical compression. The result is 
idiocy or imbecility; the development of 



the higher intelligence, of judgment, and 
reasoning is impossible." 

Persistent malnutrition of the body 
sooner or later shows its pernicious effects 
upon the processes of the mind. This is 
particularly marked in children who are 
approaching the period of pubescence. 
This is the period when the parents and 
teachers begin to notice in the child a 
lack of concentration and interest in 
study; perhaps an irritability in temper 
and a disposition to contentiouness is de- 
veloped, or the child becomes dull and 
apathetic, loses interest in play, and per- 
haps shows more or less distaste for 
association with friends. The child falls 
behind in the school work, perhaps be- 
comes discouraged and either wants to 
leave school or plays truant; or a vicious 
temper may develop which constantly gets 
the individual into trouble with teachers 
and associates; or a disposition to un- 
truthfulness is developed, or to appro- 
priate, for individual use or otherwise, 
property belonging to another. These 
conditions are all the result of a disordered 
mind dependent upon the malnutrition 



and septic poisoning from which the child 
is suffering, and call for medical, surgical, 
and dental aid, and sympathy from those 
responsible for the up-bringing of these 
unfortunate children. But left to them- 
selves, without proper treatment, and con- 
stantly reprimanded and punished for 
their derelictions, for which they are only 
partially responsible, they soon become 
the incorrigibles of the school and later 
may enter the ranks of the criminal class. 
The period of pubescence is one of great 
importance in the development of chil- 
dren. During this period — in this climate 
between the ages of 13 and 15 years — 
the boy or girl passes from childhood to 
manhood or womanhood. At this period 
great physical changes take place. The 
organs of reproduction begin to assume 
their function and decided changes in the 
personal characteristics of the individual 
take place. It is a most critical period 
in the life of the boy or girl, a period 
when the greatest wisdom is called for 
upon the part of parents and teachers to 
guide them aright. It is at this time that 
children with neurotic tendencies are apt 
to develop undesirable traits of character, 



or that those who have inherited tendencies 
to instability of mind are liable to suffer 
from mental disease. 

In those with an unstable nervous sys- 
tem — neurotics — chorea, neurasthenia, 
and epilepsy may be developed as a re- 
sult of the added nervous strain caused by 
the establishment of new functions, and 
the mental anxiety often manifested by 
those who, through ignorance of the cause 
for these changes in their physical con- 
dition, are unable to understand them. It 
is positively wicked for parents or those 
who have the charge of rearing children 
to allow them to approach this important 
period in their lives without preparing 
them to understand — of course in a mod- 
est way, such as a true father and mother 
will know how to do — these changes in 
bodily functions, and the new desires and 
aspirations which go with them. 

The winter has seen many cases of 
chorea in growing children that were 
directly traceable to irritation from bad 
teeth, superimposed upon an unstable 
nervous organization, or upon a nervous 
system weakened by too close applica- 
tion and too long hours spent over their 



school work and in which they were taxing 
their nervous energy to the limit of 

Inattention in children is always the 
result of nerve exhaustion. 

A tired person, either child or man, can- 
not fix the attention urjon any subject, no 
matter how interesting, except for a short 
period of time. The mind constantly 
wanders to other things, and when 
brought back to the subject by an effort 
of will it cannot be held. Concentration 
seems impossible. The child who is 
suffering from nerve exhaustion inherited 
or acquired, in the form of hysteria or 
neurasthenia, is unable to fix the attention 
upon his studies, he lacks concentration 
of attention, and consequently he falls 
behind the healthy child and is soon 
classed with the backward and delinquent 

When the writer was a boy in school, 
inattention and lack of concentration upon 
the work in hand was considered a M wil- 
ful disobedience," and punished with 
stripes from a vicious rattan, and this 
with as little justice as would have been 
the punishment of a child positively ill. 



In 75 per cent, of cases of inattention, 
the child is a sick child, for his nerves are 
tired. He was either born so or he has 
become so through unhygienic and un- 
sanitary methods of living, and he is no 
more responsible for his inattention and 
inability to concentrate his mind upon his 
studies than he would be if sick from any 
other cause. Children of this character 
are completely incapacitated for pro- 
longed serious application to any form of 
mental labor. 

Ajnerican children are, as a rule, en- 
dowed with a very sensitive nervous or- 
ganization, and are therefore more liable 
to a nervous break-down under severe 
stress than are children with a more 
phlegmatic temperament. 

The correction of irregularities of the 
teeth by mechanical means is often re- 
sponsible for the establishment of nervous 
affections when the operation is too 
rapidly performed, particularly if the 
child possesses a highly endowed nervous 
organization, or is under heavy and ex- 
acting mental and nervous strain from 
ill-advised crowding in school work. 

When any severe strain is to be placed 



upon the nervous endurance of a growing 
child, like that of correcting irregularities 
of the teeth, or expanding the dental arch 
and superior maxillary bones, to increase 
the width of the nasal passages so neces- 
sary in children with arrested develop- 
ment of these bones, and also during 
orthopaedic operations, they should be re- 
lieved of all school work and all other tax 
upon nervous energy. Orthodontists and 
orthopaedists are beginning to appre- 
ciate this fact, and children who are 
undergoing these operations are not so 
often compelled to suffer such undue 
nervous strain as formerly. 

Epilepsy may also be developed in the 
same way under like circumstances. It 
is a question therefore of considerable 
importance whether children who have 
inherited a neurotic temperament, with 
a tendency to epilepsy or insanity, should 
ever be submitted to any undue strain of 
this kind. 

In persons of neurotic temperament, 
whether children or adults, slight irrita- 
tions are sometimes productive of grave 
results, as, for instance, in the case of 
a young man about 20 years of age, who 



came under the observation of the writer 
some years ago, who had developed 
symptoms of Jacksonian epilepsy, and 
was referred to him for critical examina- 
tion of the teeth, and in which no dental 
disease was discernible. Later the 
patient underwent another and more ex- 
acting general physical examination, 
when the only lesion that could be dis- 
covered was a slight fissure in ano — 
fissure of the rectum. The cure of this 
lesion, which had caused but slight irrita- 
tion and discomfort, removed all the 
symptoms of Jacksonian epilepsy. 

Professor Upson ! mentions a young 
physician who was apparently a con- 
firmed neurasthenic, but was perma- 
nently cured upon the discovery and 
excision of a rectal ulcer. 

1 Cleveland Medical Journal, 1909, p. 455, 




Deformities of the body, whether of 
congenital or acquired origin, often warp 
the disposition of an otherwise correct 
child, and later develop thoughts, tenden- 
cies, and actions which, if neglected, may 
become the forerunners of a perverted, 
vicious, immoral, or criminal life. 

It is a well-known fact that irregu- 
larities of the teeth and malformations of 
the jaws are common among the insane 
and the habitual criminals. 

In a joint paper upon "Studies of Crimi- 
nals " 1 prepared by Drs. G. Frank 
Lydston and E. S. Talbot, of Chicago, in 
1881, they give the results of the ex- 
amination of 477 criminals of the habitual 
class, confined in the State penitentiary 
at Joliet, 111., of whom 468 were males 
and 9 were females. Of the whole num- 
ber three were Chinese, 18 were negroes, 

Talbot's Osseous Deformities of the Head, Face, Jaws, 
and Teeth, third edition. 



and the remainder were whites. These 
criminals were examined for the purpose 
of ascertaining how many of them had 
osseous deformities of the head, face, and 
teeth, with the result that 63.94 per cent, 
out of this number had some form of 
osseous deformity of the jaws and mal- 
arrangement of the teeth. In the 
majority of the negroes the jaws were 
well developed. One had a partial V- 
shaped dental arch, one a saddle-shaped, 
one a V-shaped arch, and in one the left 
body of the lower jaw was found to be much 
smaller than the right. The bones of the 
head and face were also well developed. 

The three Chinese were all sub-micro- 
cephalic — small headed — with very small 
jaws, and two of these had saddle-shaped 
dental arches. "It is worthy of note," 
they say, " that the nine females exam- 
ined had large and well-developed jaws 
with normal dental arches." 

The histories of these cases " plainly 
show at a glance the physical degeneracy 
and often the bad heredity of the sub- 
jects." They also invite attention to a 
noteworthy fact, that " The cases which 
most nearly approximated the normal 

IS 193 


type of development were in sporadic 
criminals. The most markedly aberrant 
types were found in the imported 

Defects of the palate, both in the bony 
vault and in the velum, are common 
among the defective and degenerate 
classes. Talbot reports having found 
congenital division of the palate in 14 
out of 150 prostitutes, vicious implanta- 
tion of the teeth in 62, anomalies of the 
facial bones in 64. In 700 cases of in- 
sane patients confined in the Dunning 
Asylum, Cook County, Illinois, taken at 
random, and of whom 430 were men and 
270 were women, he found 214 with ab- 
normal development of the maxillary 

Dr. Henry J. Jaulusz, of Pittsburgh, 2 
declares : " The child with poor teeth 
probably will become the murderer, burg- 
lar, or defective of the future. The em- 
bryo criminal may be changed into a 
preacher or a great civic teacher by a 
simple dental operation. The teeth of 
children charged with crime should be ex- 
amined by an expert, and if found 
defective they should be put in first-class 

2 Oral Hygiene, March, 1911, p. 176. 


order by the State.'' He declared also, 
" that he could tell instantly by looking 
at the teeth of a child what the criminal 
tendencies are, if any exist. After nu- 
merous tests, I am convinced that it is 
more important to look after a child's 
teeth than to send him to Sunday School 
or to a reformatory. The teeth of the 
majority of children are neither properly 
cleaned nor regulated. 

"It is certain that abnormal ideas will 
take possession of the child's mind under 
these circumstances. Take the case of a 
tooth that is too close to another : the life- 
feeding vessels are cut off. The nerves 
become inflamed. The inflammation pro- 
ceeds along the channels to the brain. 
It is the same with decayed teeth. The 
trouble goes to the brain and creates ab- 
normal ideas and vicious tendencies. 
ALmong sixty-two deficient children I 
examined in New York schools, I found 
all had defective dental organisms. Xot 
one of them knew the Lord's Prayer, and 
several of them had never heard of God. 
They were reported as cruel to animals, 
prone to lie, steal, and disobey their 



" Statistics gathered by Mr. Howell 
Cheney, of the Connecticut State Board 
of Education, on the relation existing 
between physical defects of school-children 
and their retardation in the grades, show 
conclusively that children who are re- 
tarded are almost invariably physically 
defective and that among the most im- 
portant defects are decayed teeth." (Supt. 
Buckley. ) 

Dr. James A. Britton, the Detention 
House physician of Chicago, says, " We 
have every reason to believe that an aching 
tooth is frequently the first cause of ir- 
regularity in school attendance, and every 
one knows that irregularity in school 
attendance is one of the first steps towards 
the juvenile court." 

The case of Morris Krause, found in the 
report of the tests made at the Marion 
school (Part III), is a remarkable show- 
ing of what may be accomplished by oral 
hygiene and dental treatment under the 
most adverse circumstances that could be 
imagined. This boy was reported as the 
terror of the school, lawless, selfish, un- 
trained, incorrigible, a truancy case, and 
one year behind his grade. His oral con- 



dition was among the worst in the class. 
This boy, under proper hygienic care of 
the mouth and the curing of the diseased 
oral conditions, was changed to one of 
health and happiness. From the terror 
of the school, he became a conscientious, 
diligent, faithful student, interested in his 
work, and made the highest increase in 
efficiency of any child in the class. His 
record shows an increase for the first ten 
months of the test of 204.3 per cent. 

Irregular teeth together with ill care 
are, according to Dr. John F. Detweiler, 
of London, 3 conducive to crime. He 
says: " From statistics which myself and 
others have gathered, we have traced a re- 
markable percentage of crime among men 
and women under thirty years of age to 
bad teeth. The Dental League, of Lon- 
don, co-operates with the London consta- 
bles in collecting these figures, and I have 
made many examinations of persons who 
have been arrested. 

" Teeth which are not perfectly aligned 
in the mouth seem to make persons un- 
reliable and finally give them a criminal 
instinct. This discovery is in its infancy, 

3 Oral Hygiene, April, 1911. 


and I believe many strides will be made 
along this line in the course of the next 
few years." 

In speaking of the results of the ex- 
amination and treatment of the teeth of 
the school-children he said: " It has been 
most successful. We have kept records 
of the patients, seeing what progress they 
made before and after treatment. In 
nearly every case, after the teeth had been 
treated, there was marked improvement 
in the pupil's work at school." 

Children with narrow, contracted upper 
jaws and irregular teeth have correspond- 
ingly contracted nasal passages and very 
often abnormal growths in these passages, 
such as enlarged turbinates, thickened 
mucous membranes, deflected septum, or 
adenoids, which further constrict the air- 
passages and decrease the amount of oxy- 
gen entering the lungs, thus materially 
interfering with healthy growth of body 
and mind, and rendering these unfor- 
tunate children nervous, irritable in dis- 
position, and dull in intellect. 

Such children by the perversion of their 
natural healthy tendencies, through these 
physical defects, often become morose, 



suspicious, contentious, incorrigibles that 
cannot be governed at home, and who, if 
sent to schools of correction, are only made 
more incorrigible by their treatment, and 
when released are apt to develop criminal 
tendencies, if they have not already been 
developed through unjust treatment. 
These children do not deserve punishment, 
for they are not responsible for these tend- 
encies. What they need is medical, surgi- 
cal, and dental care. Instead of treating 
them as criminals and confining them in 
houses of correction, they should be placed 
in hospitals where these physical defects 
may be remedied and they be given an 
even chance in the world to become use- 
ful, self-respecting, honorable men and 

Experimental work along these lines 
has already been undertaken by several 
surgeons in various cities of the United 
States, the results of which will be looked 
for with great interest. Judge De Lacy, 
of the Juvenile Court of Washington, 
D. C, has interested himself in these ex- 
periments, and is doing all he can to secure 
a proper recognition of the fact that many 
children become immoral and criminal 



because of some physical disease or de- 
formity that can be corrected by medical, 
surgical, and dental science and a pros- 
pective bad career changed into a good 

Prof. H. S. Upson reports the case of a 
thoroughly bad young man, aged 21 years, 
confined in the Cleveland Workhouse, who 
was cured of his moral and mental ab- 
errations by the removal of two impacted 
upper molars, two abscessed lower molars, 
and an upper lateral incisor which showed 
evidence of absorption and marked ab- 
scess. This young man was as a boy 
unusually bright, truthful, and honest. 
Was neurotic in temperament, nervous, 
and at times had tremors, when two years 
old had a convulsion, but none since. 
Father's aunt was insane, but no other 
evidences of mental or moral aberration 
in the family. Had a good record in 
study and deportment until he entered 
high school; was mischievous, but finished 
the course. Soon after, at the age of 16 
years, he began to develop a penchant for 
stealing, burglarized several stores, and 
finally robbed a post-office, for which 
crime he served two years in a reforma- 


tory. At the age of 19 years he was 
liberated from the reformatory and for a 
time thereafter engaged in various em- 
ployments. Later was sentenced for 60 
days to the reformatory for assault and 
battery, he having " held up " a man on 
the street. He was restless, irritable, and 
contentious; had violent "spells" when 
he raved about the house and dragged 
his bedding to the floor and slept upon 
the bare springs of his bed. Sometimes 
he talked to imaginary persons, or would 
hold his shoes in his hands and talk to 
them. Since the operations, he sleeps 
quietly, is seldom irritable, laughs natu- 
rally, is cheerful and happy, and has lost 
all desire to do wrong. 




Dipsomania is a neurosis, usually in- 
herited. It is characterized by an uncon- 
trollable desire for indulgence in alcoholic 
stimulants, preceded by great nervous 
depression, restlessness, severe fatigue, 
inattention to duties, and irritability of 

The desire for indulgence in alcoholic 
stimulants comes in storms or waves, and 
in this respect is a characteristic neurosis. 
The intervals may be long or short, some- 
times several months may intervene 
between the storms. These people often 
lead a dual life, occupying positions of 
honor and respectability in the commu- 
nities in which they live, no one suspecting 
for a long time that they were given to 
periodic fits of the most degrading 
debauchery. They are always very care- 
ful to hide themselves during these times 
in some distant place where they are 


unknown and not likely to be discovered. 

Drunkards are degenerates, and belong 
to that class of degenerates that Maudsley 
and Ball designate as " border-land 
dwellers," — that is, dwellers on the border- 
land between reason and pronounced 

Morel says, " Degeneracy is a morbid 
deviation from an original type." Fere 
says, " Vice, crime, and madness are only 
distinguishable from each other by social 

Most degenerates are lacking in the 
sense of morality and right and wrong 
and are weak in will power. The dip- 
somaniac, when he is overtaken by one 
of his nerve storms, is unable to exercise 
his will power, and loses all sense of moral 
rectitude, and cares nothing for the right 
and wrong of his actions, either against 
himself or others. He will lie, steal, or 
even commit murder if need be, to gratify 
his insane desire for that which will, for 
the time being, lift him out of his awful 
depression and give him forgetfulness and 
oblivion. When the storm is on, he is 
irresponsible for his actions; he is insane. 

Alcoholic indulgence, when carried to 



excess, is always productive of physical 
disease. Chronic alcoholism is generally 
accompanied with pathologic changes in 
the blood-vessels, arteriosclerosis — harden- 
ing of the arteries ; sclerosis of the liver — 
hardening of the liver ; nephritis — inflam- 
mation of the kidneys; meningitis — in- 
flammation of the covering membranes of 
the brain and spinal cord; and cerebral 
atrophy — wasting or starvation of the 
brain-cells. These pathologic changes re- 
sult in progressive mental conditions, such 
as impairment of memory, loss of business 
acumen, disinclination for all mental pro- 
cesses. Thought and speech, which were 
originally refined, becomes coarse and 
vulgar; his dress untidy or slovenly. 
When reasoned with about his change in 
habits he feels that he is abused. Com- 
plains that his family and friends have all 
turned against him and that they are to 
blame for the misfortunes that have come 
upon him. Such an individual is a " bor- 
der-land dweller." 

In the preceding chapter the writer has 
called attention to the fact that de- 
formities of the face, jaws, and teeth are 
very common in the criminal classes and 


Fig. XI. 

Impacted Cuspid, Upper Jaw. Dried specimen. (After Dr. Oyer.) 

Fig. XII 

Inverted Upper Third Molar. Living subject. (After Dr. Cryer. 


the insane, also that diseased conditions 
of the teeth and mouth and deformities 
of the face and jaws are common among 
the children who are charged with crime, 
and that in some cases the correction of 
the attendant deformity or diseased con- 
dition has resulted in a complete change 
for the better in both physical and mental 

That manv cases of drunkenness, 
neurasthenia, melancholia, and insanity 
are due to mental overwork, business 
worries, mental shock, physical shock from 
traumatic or surgical injuries, child-bear- 
ing, pelvic diseases, ansemia, general 
toxsemia from sepsis or the continued 
fevers, specific disease, and heredity, etc., 
all will agree; but it is a new thought 
that there may be added to this long list 
of causes, oral sepsis, the irritations and 
perversions of functions due to deformities 
of the teeth, face, and jaws and to reflex 
dental irritations from malposed or im- 
pacted teeth. (Figs. X, XI, XII.) 

Prof. H. S. Upson found in his investi- 
gations upon the relationship of dental 
diseases to moral aberration, that irrita- 
tions of practically a painless character 



were frequently responsible, as the sequel 
showed, for grave mental conditions. 

" In the course of an investigation upon 
the subject of impacted and otherwise 
diseased teeth in causing insanity," he 
says, " I examined in the winter of 1908- 
09 eighteen of the younger inmates of the 
Cleveland Workhouse with a special view 
to impaction of teeth, and incidentally a 
few of the older men for other lesions. Of 
the eighteen cases, ranging from 18 to 
25 years of age, twelve showed multiple 

" A number of these were operated 
upon and a part of the irritation removed. 
It was difficult to obtain histories, and in 
most instances impossible to follow the 
cases and give them adequate relief from 
the various lesions from w r hich they 
suffered. In the course of the investiga- 
tion three older patients were seen in- 
cidentally, and operated upon as a matter 
of faint hope but without much expecta- 
tion of a favorable result. The outcome, 
however, has been unexpectedly favorable 
in two cases; no report has been received 
from the other one. 

" One patient, Tom L., had been com- 



mitted to the institution ninety-three times 
during the last thirty years for drunken- 
ness and fighting. Although liquor 
always made him obstreperous, he was, 
when sober, very anxious to stop drinking 
and was pleasant and capable. Radio- 
graphs showed abscesses at the roots of 
two old stumps of teeth. These were ex- 
tracted in February, 1909. Tom has 
since told me that before the extraction 
he had some toothache, severe pain in the 
head and sleeplessness, and in addition a 
periodic craving for drink which neither 
he nor any one else had ever connected 
with the dental manifestations. At the 
last report he had been entirely sober and 
faithfully working for fifteen months. 

" The other patient, a woman forty 
years old, w T as also unusually capable and 
faithful in her sober moments. She had, 
however, been committed twenty or thirty 
times in the last ten years for drunken- 
ness. She had been sleepless, had a good 
deal of headache in the temples and in 
the back of her head, and had suffered 
with terrible toothaches for several years 
past. The drinking had in her case never 
been associated by any one with her bad 



teeth. She was well nourished and of 
fairly good color. On inspection, the 
nineteen remaining teeth in her jaws were 
all found to be badly decayed and the 
gums deeply ulcerated. They were ex- 
tracted. Following their extraction she 
went on one more spree, but at last report 
had been entirely sober and at work for 
nine months. 

" These patients appear to be cases of 
periodic aberration caused by pain. There 
is no evidence, however, to show that the 
craving for drink is in such cases really 
due to any pain recognized as such in 
consciousness, or localized in any way. 
It is rather the result of vague but intense 
emotion, in the form of either unrest, with 
depression, or elation, with its accompany- 
ing lack of self-control. 

" Recovery in these cases seems to have 
been facilitated by an unusual original 
endowment, both moral and mental. Such 
mentalities, unless completely shattered, 
may return to a condition of stable 
equilibrium on the removal of even a long- 
continued irritant cause of aberration. 
The chances of recovery are of course 
much better in early cases." 



This same investigator, in a preliminary 
report made to the Clinical and Patho- 
logical Section of the Cleveland Academy 
of Medicine upon the Effects of Oral 
Sepsis and Dental Irritation upon Neu- 
rotics and the Insane, * says: " I desire to 
call your attention to a familiar subject: 
the melancholy of toothache. The point 
is that the depression sometimes comes 
without the ache. 

" The principal symptoms caused by 
dental lesions are : First, pain in the tooth ; 
second, pain elsewhere, especially in the 
head; third, vasomotor symptoms, chills, 
thrills, flushes, sweating ; fourth, insomnia ; 
fifth, melancholy; sixth, muscular twitch- 
ings; seventh, fever, especially when 
pyorrhoea is present; eighth, rapid or ir- 
regular pulse. All of these symptoms 
are important. If in the absence of the 
diagnostic sign toothache, melancholy may 
run into melancholia ; or if sweating, weak- 
ness, and flushing, caused by bad teeth, 
may constitute neurasthenia; or if in- 
somnia, unaccompanied by dental pain, 
may result, it becomes important to make 
the diagnosis and remove the cause." 

1 Cleveland Medical Journal, vol. vi, p. 458. 
14 209 


He then outlines two cases, the first 
one evidently a case of septic irritation 
due to a devitalized tooth, and the other 
of reflex dental irritation due to an im- 
pacted third molar. 

Case I. — " A robust mechanic, aged 28 
years. Three weeks before being seen, 
had been moodily accosted by his wife that 
she believed she was losing her mind. It 
immediately occurred to him that he might 
be losing his mind. He slept little that 
night or the succeeding nights, gave up 
his work, and spent his days in fear of the 
asylum. Tonics and assurances were of 
no avail. The only lesion that could be 
discovered w r as dental caries. The filling 
of a deep cavity extending into the pulp 
was followed by prompt recovery and he 
returned to work. At no time had there 
been toothache or other pain, but dizzi- 
ness and sweating had been noted. 

Case II. — "An unmarried woman, aged 
27 years, a teacher. For a year had been 
profoundly melancholy, with intractable 
insomnia, delusions of various deadly 
sins, and entire hopelessness of recovery. 
Restlessness was extreme; tonics and 


local uterine treatment were of no avail. 
As a last resort the teeth were examined. 
They were apparently in perfect condi- 
tion. A radiograph showed, however, an 
impacted right upper third molar tooth 
pressing against the second molar, a con- 
dition obviously capable of causing ir- 
ritation. The tooth was removed and in 
about a week the symptoms began to 
improve. Recovery was complete in six 
or eight weeks and has persisted for six 
months." He says further, " The in- 
ference is warranted that the teeth in 
melancholies, neurasthenics, and those 
afflicted with insomnia should share the 
honors of a medical examination equally 
with the contents of the chest, abdomen, 
and pelvis, and, when diseased, should 
be cured." 

In a more recent paper, 2 " Painless 
Dental Disease as a Cause of Neuras- 
thenia and Insanity," he says: " The ob- 
ject of the present paper is to put on 
record a few observations made during 
the past two years in a broad and impor- 
tant field, that relating to dental diseases 
in connection with nerve strain and with 

2 Cleveland Medical Journal, vol. viii, p. 447. 


the psychoses, melancholia, mania, and 
dementia precox. 

" Although typical cases may occur in 
which a diagnosis of one member of this 
nervous and mental group is warranted, 
in many patients the symptoms blend in 
such a way that no sharp dividing line 
can be drawn. Most of the mental cases 
are nervous, most of the nervous cases 
have a mental substratum. 

" On the physical side there is an equal 
complexity of conditions. Diseases of 
the oral, abdominal, or pelvic viscera are 
present as an exciting cause in conditions 
of insomnia, simple depression, purely 
emotional excitement, and in the more 
severe degrees of emotional disorder with 
or without delusions, so that what one 
considered normal emotions verge by im- 
perceptible gradations into severe cases 
of emotional and mental disorder. The 
physiologic and pathologic are one. It 
is necessary to proceed from the simple 
to the complex in sifting these cases, in 
order to determine whether some or all 
of them are, in their mental symp- 
toms, dependent on underlying physical 



" One of the simplest dental lesions is 
impaction. When a tooth is formed in 
the jaw-bone with its axis wrongly 
directed, it is often prevented by impact 
against another tooth from appearing 
outside the bone or through the gum. 
The result is pressure against the peri- 
dental membrane, in some instances 
accompanied by severe toothache or 
neuralgia. In most cases no such pain 
is present. 

" Beginning with the known fact that 
an impacted tooth is not only a stigma — 
deformity — but a lesion, capable of caus- 
ing agonizing pain, and the further fact 
that long-continued intense pain may 
cause delirium and insanity, in fact, that 
most pains are associated with consequent 
mental phenomena, experiment and ob- 
servation must determine whether these 
severe nervous, mental, and moral symp- 
toms are due to pain or may occur in 
the absence of pain." 

In this connection he records from his 
private practice seven cases that were 
dependent upon reflex dental irritation 
or septic conditions of the mouth. 

Case I " was one of insomnia and mild 



melancholia in a merchant 40 years of 
age. Trouble began four or five years 
ago by occasional attacks of sleepless- 
ness and mental depression. Two years 
ago depression and insomnia became per- 
sistent and annoying. At times depres- 
sion was followed by elation also attended 
by insomnia. These conditions were im- 
proved by rest and became worse by work 
and worry. Had no headache, no 
neuralgia, and no toothache, except 
occasionally from an ulcerated tooth, 
which was relieved by evacuating the pus. 
Had parted with three molar teeth during 
the last four years on account of abscess 
at the roots. Radiograph showed left 
upper third molar was impacted against 
the roots of the second molar, high in the 
jaw-bone. The second molar was dead, 
but showed no evidences of abscess. Both 
teeth were extracted. The roots of the 
second molar showed evidences of absorp- 
tion from pressure. The patient made a 
progressive recovery. Sleep was better 
two nights after the operation. Depres- 
sion has disappeared and the patient has 
made a practical return to health." 

Case II "is one of severe delusional 
and suicidal melancholia in a teacher 27 



years old. When first seen she had been 
profoundly melancholy for more than a 
year. Had persistent insomnia and many 
delusions, that her mind was gone, had 
never been quite sane, and that she had 
committed various dreadful sins. Treat- 
ment by tonics, by suggestion, change of 
scene, and treatment of the uterus were 
of no avail. After a year of useless effort 
the teeth were examined, and found in 
apparently normal condition. Radio- 
graph showed an impacted upper third 
molar which was removed under anaes- 
thesia. Patient had never in her life 
suffered with a toothache or any other 
disease of the teeth or jaws. She began 
to sleep well within a week or ten days 
after the extraction of the tooth. Her 
return to normal health was steady, and 
was typical in the fact that the delusions 
persisted longer than the melancholy. 
In such patients it is practically invariable 
that the emotional health is recovered 
first and the delusions are got rid of after. 
The only physical disease in this case 
was the impacted tooth; the other viscera 
throughout being healthy. The recovery 
has been complete." 

Case III " is an example of dementia 



precox in a man 41 years of age. Was 
well as a boy and until the age of 24; 
then he began to have periods of sleep- 
lessness at intervals of six months or a 
year. After a few nights without sleep, 
would become flighty and irresponsible. 
Had some periods of catalepsy, and at 
times ran away from the institutions in 
which he was being treated. During the 
intervals when he had a fair amount of 
sleep his mental condition was better, but 
was far from normal, being irritable and 
of unhappy disposition. 

"Examination disclosed an impacted 
upper third molar, moderately angled 
against the second molar. The third 
molar was extracted. For several months 
previously the patient had been suffering 
from insomnia, but began to sleep better 
and to feel more quiet two or three days 
after the operation. The gain in health 
has been progressive over several months, 
and he has since been in a thoroughly 
normal condition. Does not sleep well 
without sedatives of some kind, but has 
lost his undue irritability and other 
accompanying symptoms." 

Case IV " is one of dementia precox 



of a severe and continuous type in a girl 
19 years of age, who has for eight months 
drifted gradually into a condition of men- 
tal aberration. Her case was marked by 
an active and persistent obstinacy. She 
was so restless that she had to be re- 
strained night and day. She resisted all 
attempt at control ; her delusions were ex- 
pressed more and more actively until her 
talk became mere mutterings. Moaned 
continually as if in distress, but denied 
any pain whatsoever. Was obstinately 
sleepless night after night. Loss of sleep, 
refusal to eat, and constant activity day 
and night had brought her to a miserable 
condition of pallor and emaciation. 
Etherization was necessary in order to 
take radiographs. A cuspid tooth and all 
third molar teeth were found impacted 
and removed. Improvement began in the 
symptoms within two weeks after the 
operation. Two or three months after 
the operation, she had a relapse following 
a digestive disturbance, which took the 
form of attacks of loud shrieking, which 
began early in the morning after awaking, 
and these attacks were continued for five 
or six weeks. Improvement, however, 



was practically continuous; mental health 
was established within six or eight months 
after the operation. Has occasional 
severe headaches. Has an occasional 
sleepless night. The left lower molar, 
which is dead and the roots not filled to 
the ends, and the filling rough and over- 
hanging, was not treated, and it is not 
certain that there may not be other dental 
difficulties at this time." 

Cases V and VI " illustrate the fact 
that dental irritation of a severe type does 
not always result in insanity, but may 
cause nervous symptoms, neurasthenia, or 
disturbances in the functions of the in- 
ternal viscera. These cases are father 
and son and show heredity in nervous 
and mental troubles. The father was a 
man of 57 years of age. When 13 or 14 
years old began to show nervousness by 
biting his nails. Continued in fair health 
until 26 or 27 years old, when his digestion 
began to suffer. Had so-called nervous 
dyspepsia in a severe form, followed by 
prolapse and dilatation of the stomach, 
and has had a good deal of digestive 
trouble ever since. Radiograph revealed 
the right upper third molar in an im- 



pacted position. Its removal was fol- 
lowed by prompt disappearance of a very 
annoying feeling of distress in the head 
which had been present for many years. 
It was not pain, but a maddening indefi- 
nite pressure, which caused restlessness 
and strong impulsion to escape from an 
intolerable tension. Relief has been com- 
plete for something over a year. 

" In the son, the nervous manifestations 
go back to the time when he was four 
years old, when he had twitching of the 
face and the extremities. Otherwise he had 
been fairly well though not robust. At 
the age of 17 years he became consider- 
ably worse, the twitching was more 
marked and digestion and circulation had 
begun to fail perceptibly. Restlessness 
was extreme, but no organic disease could 
be found anywhere in the body. Radio- 
graphic examination showed an impacted 
right upper third molar tooth, almost 
identical in appearance with the one in 
the case of the father. In addition both 
lower third molars were impacted at a 
high angle, and the left upper third molar 
was retained high in the jaw. The third 
molars were all removed, but sufficient 



time has not yet elapsed for complete 
recovery. He is at present convalescent, 
fairly well, working hard, and much less 

Case VII. — This is evidently a case of 
melancholia of a simple type due to 
slovenly dentistry, and, fortunately, was 
easily corrected. 

" The patient, a woman 37 years old, 
had always been well until three or four 
years ago, when she began to experience 
a curious feeling in her throat when she 
swallowed, but without pain. The feeling 
was sometimes better, sometimes worse. 
For several years had been much de- 
pressed. Worries about her health and 
other things; has at times been sleepless. 
Has had no toothache and no headache, 
but had one attack of facial neuralgia 
which stopped after treatment of the dis- 
eased roots of a tooth in the lower jaw. 
Examination of the teeth showed them 
in fair condition, but with a good many 
ragged fillings and badly fitting bridges. 
Upon the correction of these conditions 
by the dentist, she promptly recovered 
from her melancholy, and at last accounts 
was almost free from the hysteric feeling 
in her throat." 





The oral hygiene propaganda recently 
established in this country by the Oral 
Hygiene Committee of the National 
Dental Association should receive the 
most active and interested support of our 
general and State governments, city and 
county boards of health, physicians, den- 
tists, school-teachers, and the public 
generally. Similar movements had already 
been established in various sections of 
Germany and England and are doing 
great good. 

This movement not only contemplates 
the establishment of free dental clinics, 
but goes much deeper into the subjects, 
for it proposes to take the advanced 
position that prevention is better than 
cure. With this end in view the Oral Hy- 
giene Committee have proposed to enter 
the public schools and to begin their 
educational and practical work with the 
little children, selecting as their first field 
of labor the schools in the ghetto districts 



of our large cities. In Cleveland, Ohio, 
Rochester, N. Y., New York City, 
Chicago, 111., Washington, D. C, and 
various other large centres of population, 
the school boards and the boards of public 
health have become interested, and in 
some instances have appointed public 
lecturers and dental inspectors for the 
public schools, whose services are paid for 
from the public treasury. 

The Oral Hygiene Committee and 
several dental societies have had lectures 
and lantern exhibits prepared, which may 
be obtained for public education free of 
cost. In this way it is hoped a general 
interest may be created in the public 
mind of the value of oral hygiene as an 
important public health measure, while 
dental and oral inspection and treatment 
will demonstrate the value of clean and 
healthful mouths as factors in establish- 
ing and maintaining a healthful condition 
of body and mind. 

The Oral Hygiene Committee of the 
National Dental Association, in conjunc- 
tion with the Oral Hygiene Committee 
of the State of Ohio, and the Cleveland 
Dental Society, with the co-operation of 



the Cleveland School Board, recently es- 
tablished, at the Marion School in the 
ghetto of Cleveland, a severe test upon 
the value of oral hygiene as a promoter 
of general good health and mental ac- 
tivity. The following is a brief report 
of ten months' work in this school with 
a class of twenty-seven children, all of 
whom were classed as backward and 
delinquent children and all of whom had 
very bad teeth. In fact they were chil- 
dren selected by the dental inspector as 
having the most unclean mouths and the 
largest number of defective and diseased 
teeth of all the pupils in the whole school. 
The dental inspector examined eight 
hundred and forty-six children at the 
Marion school, and found that 97 per 
cent, were in need of dental and oral 

"Cleveland, O., Feb. 18, 1911. 
To the Honorable Members of the Board 
of Education, Cleveland, O. 

The National Dental Association, the 
Ohio State Dental Society, and the Cleve- 

15 225 


land Dental Society beg leave to submit 
the following report relative to the work 
undertaken under a resolution adopted 
by your Honorable Board on November 
1, 1909. 

We regret our inability to render a 
report to you upon the date set for the 
same, but since January 1st our time has 
been devoted to securing statistics show- 
ing results of the work. 

It is also a source of deep regret to 
us that, owing to the serious illness of 
one of the members of our committee 
who had the principal part of the work in 
charge, we were delayed in beginning the 
work for about three months; and as a 
result of this delay we were unable to 
complete all the work we had originally 

After securing the equipment and or- 
ganizing our working forces, the com- 
mittee became aware of the fact that, with 
the work scattered over as broad a terri- 
tory as originally planned, it would be a 
very difficult matter to secure tabulated 
reports of results. It therefore seemed 
wise that a number of children, represent- 


ing different classes and t}^pes of pupils 
to be found in the schools, be selected to 
make a careful and scientific test relative 
to the amount of improvement shown as 
a result of correcting unhealthy oral 

In Marion School medical inspection 
had been in progress something over a 
period of three years, and whatever bene- 
fit was to be shown from the same would 
have had sufficient time to affect the 
records of the children in that school to 
such an extent that it would not make 
a perceptible difference in the records of 
the children. We therefore asked Miss 
O'Neill, the principal of the school, to 
select a class of forty children, twenty- 
seven of whom were faithful in carrying 
out the instruction given them relative to 
the care and use of the teeth. The class 
records of these children were taken for 
six months preceding the time they were 
received for care, treatment, and instruc- 
tion; and, in addition to this, psycho- 
logical tests were made under the direc- 
tion of Prof. J. E. W. Wallin, which 
would show the working efficiency of the 



child at the time he was received. These 
tests included " memory/' " spontaneous 
association," " addition," " association by 
opposites," and " quickness and accuracy 
of perception " tests. 

Here was found a considerable number 
of children who exhibited bad oral con- 
ditions, backward physical development, 
retarded mental progress, and unruly or 
immoral characteristics. Examination of 
man}^ (of the children and their school 
records showed that if the oral conditions 
were not the causes of the physical, men- 
tal, and moral backwardness, there was 
a striking parallelism. For the child 
whose mouth was unclean and incapable 
of proper mastication usually exhibited 
the conditions which the committee ex- 
pected. That is, bad oral conditions, bad 
physical conditions, mental backwardness, 
and sulky or resentful or insubordinate 
moral attributes were all closely asso- 
ciated. If one started from the other 
end of the chain, the result seemed to be 
the same; that is, the child who was 
notably deficient physically, backward 
mentally, and insubordinate was found 
to exhibit bad oral conditions. Which- 



ever end one started from, the answer 
was that the conditions ran so closely 
together that their relationships were 
worthy of investigation. 

These children were then banded to- 
gether and instructed in the care and use 
of the mouth and teeth, and a nurse, Mrs. 
Maud Van Gastle, placed over them to 
see that they followed out the instruc- 
tion given them, and test meals were 
served to show them how to masticate 
their food properly. The mouths of these 
children were then to be put in first-class 
condition and their records taken, both 
their class and psychological records, dur- 
ing the time of treatment and for six 
months succeeding treatment. To date, 
six psychological tests have been made 
and the class records taken to January 
23d; but the teeth of all the members of 
the class have not all been put in first- 
class condition. It is our purpose, with 
your permission, to make two more psy- 
chological tests upon these children and 
take the school records at the close of the 
school year, which will be about six 
months after their treatment has been 
completed, when we expect to be able to 


show a very much larger increase than we 
have been able to show to date. 

From the time the clinics were opened 
to date, the children have been undergoing 
the nervous strain incident to having den- 
tal work performed, therefore, their 
records would not be as good as under 
more favorable circumstances. The ma- 
jority of the children selected for this 
class were repeaters, many of them were 
truancy cases. 

As to the effect of our work upon this 
class, as relating to the records of the va- 
rious children, we beg leave to submit the 
following report or statement from Miss 
O'Neill, principal of the school, which 
speaks for itself and shows the value of 
giving proper instruction in this line, 
from the educational side : " 

" Marion School, Cleveland, O., Feb. 17, 1911. 

Dr. W. G. Ebersole, Chairman of the Oral Hy- 
giene Committee of the National Dental 

Dear Sir: 

I am very glad to have the opportunity of 
expressing my opinion of the work of the special 
dental class. 



As you no doubt remember, Dr. Krejci ex- 
amined the mouths of the eight hundred and 
forty-six children at Marion School. 

We selected forty of the children whose charts 
showed their mouths to be in a most serious 

Those forty children have been under treat- 
ment from May, 1910, till January 1, 1911. 
Their teeth were put into good condition; their 
habits of eating were supervised. 

The results far excel any anticipations. In 
every instance the health has improved; the 
complexion has cleared ; and with the attending 
physical uplift has come a self-respect that made 
them a very desirable element in school; which 
is more than can be said of several of them be- 
fore we began this work. 

We conducted a series of psychological tests 
planned by an expert. 

The conditions have been carried out with 
the utmost care and precision, and the children 
have almost uniformly shown an improvement. 

We believe it is a most conclusive test of the 
benefits that may be derived from a general care 
and attention to oral hygiene during the early 
years of life. 

The asset of a good set of teeth and correct 
habits of eating and breathing will be of im- 
mense value to any child w T hen entering upon 
his life career. We know that to-day a vast 
majority of our children are not so equipped. 


Trusting that some provisions for overcoming 
those handicaps will soon be made in our schools, 
I am, 

Very respectfully yours, 
(Signed) Cordelia L. O'Neill, 

Principal of Marion School." 

" In support of Miss O'Neill's state- 
ment, we beg to submit a report or 
statement from Dr. J. E. W. Wallin: 

"Skillman, N. J., Feb. 24, 1911. 
Dr. W. C. Ebersole, Cleveland, O. 
My Dear Sir: 

The study of the effects of the application of 
proper operative and hygienic oral treatment 
upon the working efficiency, mental development, 
health, conduct, and regularity of attendance of 
public school-children, which was begun in Cleve- 
land last May, is the first attempt, at least in 
this country, to investigate, by the scientific 
methods of controlled experimentation and sys- 
tematic clinical and pedagogical observation, the 
dental phase of the problem of national human 
conservation. An analysis of the tabulated re- 
sults of the serial psychological tests, of the prin- 
cipal's scholarship, and of the records of the 
medico-clinical examination of the pupils receiv- 
ing dental treatment, demonstrates (1) the bene- 
ficence of the work thus far accomplished to the 
individual pupils, in overcoming the retardation 


of mental functioning due to physical impedi- 
ments; (2) the great immediate practical value 
of dental hygiene, as a financial investment, to 
the school system; (3) the great contribution 
which oral hygiene will make toward the con- 
servation of the physical and mental vigor of 
our people ; and (4) the great desirability of mak- 
ing provisions for continuing the work of inves- 
tigation inaugurated in Cleveland, along more 
extended lines. The amount of improvement in 
some of the mental traits and capacities, as 
shown by the successive psychological tests, with 
which I have been associated, is phenomenally 
large in some of the cases. In one-half (thirteen) 
of the twenty-six cases, for which I have the 
data, the average percentage of improvement in 
the functions measured ranges from 27 per cent, 
to 168 per cent. In only three cases is the gain 
less than three per cent, (tw^o of these being 
negative). Making due allowance for natural 
growth, practice, and familiarity, there remains 
a large margin of improvement which is directly 
traceable to the prophylactic, hygienic, and 
operative treatment. I feel persuaded that we 
have here a weapon with which to combat race 
degeneration and pedagogical retardation which 
it would be unwise and uneconomical not to 
utilize in increasing measure. 

Yours very truly, 
(Signed) J. E.^W. Wallin, 
Director of Laboratory of Clinical Psychology 
in the New Jersey State Village for Epileptics." 


" Subsequent to and in support of Miss 
O'Neill's and Dr. Wallin's reports or 
statements, we herewith submit a tabu- 
lated statement of the condition of eacli 
child before treatment and instruction, 
and attached hereto will be be found said 
tabulated report. 1 

We wish to say, that, of the twenty- 
seven children in this class, all but two show 
marked improvement in working effi- 
ciency — Jacob Bernstein shows a loss of 
two-tenths of 1 per cent., and Beatrice 
Kramer a loss of 1.8 per cent. It has been 
found that, while Jacob Bernstein shows 
a slight loss from the psychological stand- 
point, his school work shows an increase 
of 19 per cent, in working efficiency. 

The highest increase in working effi- 
ciency was made by Morris Krause, who 
when taken into the class was lawless, 
selfish, and untrained, a truancy case, 
one year behind grade. This boy shows 
an increase of 204.3 per cent. 

All statements relative to the members 
of this class, either as to original condi- 
tions or final results, are based upon ac- 

1 Copies of these reports may be obtained upon application 
to the Superintendent of Public Schools, Cleveland, Ohio. 



tual facts and existing conditions, sup- 
ported by indisputable records and tests. 
And all reports and statements have been 
rigidly censored by Miss O'Neill, princi- 
pal of Marion School, whose aim and am- 
bition has been to see that nothing but 
the plain and unvarnished facts be given 
to the world at large. 

All records, tests, and information from 
which these reports are taken are at the 
command of those interested, and the 
most careful and rigid investigation as to 
the accuracy of the same is invited. 

The investigation and experimentation 
herewith reported is the first careful and 
systematic eff ort made by both the dental 
and educational authorities to prove the 
actual value of healthy oral conditions; 
and the records herein contained will be 
the means of working a complete revolu- 
tion in the methods and manner of con- 
ducting and practising hygiene and sani- 
tation, not only in connection with the 
public schools, but other educational in- 
stitutions as well, and the day is fast com- 
ing when the " powers that be " will be 
far more insistent upon a statement certi- 
fying to the healthy condition of the 



mouth than they will for a statement that 
the child has been vaccinated. 

The average increase in working effi- 
ciency for the class of twenty-seven chil- 
dren is 37.44 per cent. 

The data from which these statistics 
Were secured have been carefully pre- 
served for jwir inspection and considera- 
tion, should you desire to investigate the 
correctness of this report. 

Our committees wish to state to your 
honorable body that the increase shown 
in working efficiency to date has exceeded 
their fondest expectations, and we are 
fully convinced, that, when the children 
have had an opportunity to work free 
from the handicap of having the dental 
work done, they will show an increase of 
over 50 per cent, in working efficiency 
due to the proper teaching of the care 
and use of the mouth and teeth. 

The value of dental service, which in- 
cludes instruction not only in the proper 
care of the mouth and teeth but in the 
use of the same, is shown when we bring 
to your attention the fact that by ex- 
aminations made in June, 1909, in four 
representative schools in Cleveland, it was 



found that 97 per cent, of the public- 
school children were in need of dental 
care and treatment, and to-day we come 
to you with actual records obtained from 
pupils in one of these schools showing an 
average increase in working efficiency 
of practically ST 1 ^ per cent., and this 
before treatment is completed or the final 
tests made. 

Dental caries, or decay of the teeth, is 
the most prevalent disease of modern 
civilization, and is just as readily trans- 
ferred from child to child and from adult 
to adult as are the organisms which pro- 
duce scarlet fever, diphtheria, pneumonia, 
and tuberculosis; and it is producing far 
greater havoc than all other diseases put 
together, as the records obtained through 
your kindness will show. 

The committees firmly believe that in- 
struction given in the schools in the proper 
care and use of the teeth and mouth would 
save thousands of dollars annually to the 
State and municipality in the education 
of their wards, and this great saving too 
would be made in addition to all expenses 
entailed in taking care of the mouths of 
those children who could not afford to 



have the same done by the dental 

To illustrate in a most conservative way 
our reason for making the above state- 
ment, we will say that we have found that 
97 per cent, of our public-school children 
are in need of care and treatment. 
Records obtained from the experimental 
class at Marion School to date show an 
average increase in working efficiency of 
37.44 per cent, from a psychological 
stand-point. These children were selected 
because they showed the worst oral con- 
ditions, and the records were obtained 
when the children were undergoing the 
physical and mental strain of having these 
faulty oral conditions corrected. The 
dental work has been completed; but the 
period of experimentation does not end 
until June 1st, when the children will 
have had an opportunity of working for 
a few months free from faulty oral con- 
ditions and the nervous and physical 
strain of having such conditions corrected. 
When the period of experimentation has 
ended, judging the future by the knowl- 
edge and records obtained from the past, 
the committees feel that it is reasonably 



conservative when they say that these 
tests will show at least 50 per cent, as 
the average increase in the case of these 

With 97 per cent, of the public-school 
children in need of care and treatment, 
and with the worst oral conditions show- 
ing an improvement of from 37% per 
cent, to 50 per cent, in working efficiency, 
would it not be conservative to consider 
that, with all the faulty oral conditions 
corrected and the mouths in first-class 
condition, there might be an average in- 
crease of at least 10 per cent, in working 
efficiency for all the children in the 
schools ? 

If it costs $21.00 per child per year in 
the elementary schools for instruction 
alone, to get the cost of educating the 
child you must add to this cost the cost of 
equipment and maintenance. You must 
add to this $21.00, according to the state- 
ment of Assistant Superintendent Bach- 
man, at least 25 per cent. We therefore 
find that it costs us approximately $26.25 
a year to educate a child in the elementary 
schools. Then, from our conservative 
estimate of 10 per cent, increase in work- 



ing efficiency of every child in the public 
schools, we find that each child is doing 
10 per cent, less than he could do under 
normal conditions, and we are therefore 
paying 10 per cent, more for the education 
of that child than would be necessary un- 
der normal conditions to bring about the 
same results; or, to look at it from another 
stand-point, we could do 10 per cent, more 
or better work in the elementary schools 
at the same cost. If it is costing us 10 
per cent, more to educate a child per 
year, then we are paying $2.62% per year 
more for each child in our elementary 
schools than would be necessary under 
normal conditions. 

The records of 1909 and 1910 show a 
registration of practically 65,000 pupils 
in the elementary schools, and therefore 
upon the above basis of figuring we would 
show an expenditure of $170,625.00 a 
year to educate children handicapped by 
faulty oral conditions ; but, in making the 
above estimate, our committees placed 
their percentage at a figure which they 
are positive is less than half of what 
actual tests would show. And, if we 
double the above amount, we find that we 



are spending $341,250.00 per year to 
overcome the handicap of faulty oral con- 
ditions, most of which can be successfully 
overcome and prevented by proper in- 
struction in the correct care and use of the 
mouth and teeth. 

The condition of the mouths of the 
school-children of this country, which has 
been growing worse instead of better, is 
simply appalling. The loss in health, 
strength, and beauty is most alarming; 
while the seeming utter indifference to 
such a condition on the part of both pro- 
fession and laymen has been most aston- 
ishing. Such a condition must be met 
and overcome; and in meeting and hand- 
ling this important problem the under- 
signed will be glad to extend their counsel 
and aid. 

Thanking your honorable body for the 
kindnesses and courtesies extended, we 
beg to remain, 

Respectfully yours, 

Oeal Hygiene Committee of the 
National Dental Association, 
W. G. Ebersole, Chairman." 

The final report of this committee upon 
the scientific tests made through this class 

• 16 241 


of twenty-seven children was presented 
to the National Dental Association in the 
latter part of July at Cleveland, Ohio. 
The final psychologic tests were made 
early in May during the closing examina- 
tions of the school year. It was the pleas- 
ure of the writer to be present, with a 
number of prominent official and educa- 
tional people, to witness these psychologic 
tests, and it is our privilege to state that 
the tests were severe and absolutely fair. 
The assembled company were invited to 
take the tests with the children, and 
several complied, but were in every instance 
outdistanced by the class. To those 
readers who are interested in the full de- 
tails of the remarkable showing of this 
first scientific test upon the value of clean 
and healthful mouths and teeth and 
proper use of the teeth in mastication, we 
refer them to the Transactions of the 
National Dental Association, 1911, pub- 
lished by the S. S. White Dental Manu- 
facturing Company, Philadelphia, Pa. 

The following is a brief summary of the 
final report of the chairman of the com- 
mittee and of the final report of Miss 
O'Neill, principal of the Marion School. 




Effect of the Oral Hygiene Campaign on 
the Status of Dentistry. 

Finally your committee believes that the facts 
and records herewith presented comprise one 
of the most valuable, if not the most valuable, 
scientific discovery in the history of dentistry. 

I want, personally, to say to the president 
and to the members of the National Dental 
Association, that it was the National oral hy- 
giene campaign, as planned and conducted by 
your committee, that made it possible for the 
profession to receive the rank and recognition 
accorded it during the past year by municipal, 
state, and national governments. 

To-night this committee comes to you with 
the records obtained in carrying out a part 
of its policies, which places the dental pro- 
fession in a position to prove in dollars and 
cents the actual value of its services to mankind. 

It shows that in health conservation dental 
service plays so important a part that no other 
profession can equal, let alone excel it in the 
value of services rendered. 

" We are to-day in the maelstrom of a move- 
ment for conservation : waste and loss are 
measured from every stand-point ; the gospel of 



efficiency is being preached in every line of 
business. The scientific management even of 
the shovelling of ore, the laying of brick, or 
the manufacture of machinery is studied until 
the efficiency of the workman is raised to the 
highest degree, and loss of time or labor re- 
duced to a minimum. 


If we allow ourselves for a moment to think 
of the rapid changes that are being made in 
our mode of living, our methods of travel, 
and our conduct of life, we shall be impressed 
with the necessity for utilizing our forces to 
the greatest advantage. 

This necessity is very marked in the field 
of education. In the year of 1830 but 5 per 
cent, of our population in the United States 
lived in the cities ; to-day very close to 70 per 
cent, are so domiciled. Think of what that 
means to education! With 95 per cent, of 
the children out in the open fields, breathing 
the pure air of the country, nourished with 
food that had not undergone adulteration, and 
trained in the varied pursuits and crafts of the 
farmer boy and girl of that day, it is not 
surprising that little thought was given by 
the educator to the physical welfare of his 
pupil. . . . 



When a child was close to nature, nature 
took care to correct the imperfections made by 
unintelligent civilization. But when outraged 
nature is overtaxed by the rush and hurry of 
a city existence, she refuses to cope with the 
situation, and we are rearing a race of weaklings 
for future citizenship. 

The great need of conserving the child for 
the nation appeals strongly to us. We cannot 
send him back to the country to live; we must 
deal with the condition as it exists, hence the 
training for perfect life takes the place of his 
former simple life. 


The purpose of this paper is to give evidence 
of what may be done to increase the efficiency 
of the child if a scientific management be 

An experiment along these lines has been 
made at Marion School. Marion School is 
situated in the congested section of the city, 
and its pupils come from eighteen city blocks, 
which territory also supplies pupils to three 
parochial schools. The conditions might 
furnish results that may be found in similar 
quarters in any city. It has also furnished a 
proof of what may be done in such a community 
by fostering the higher ideals of living. 



In June 1909 there appeared at our school 
one Monday morning ten dentists and ten 
nurses or attendants, sent, by previous arrange- 
ment with the board of education, to obtain an 
idea of the condition of the children's mouths. 

Inspection was made of 846 children, and 
a dental chart was marked for each child. Out 
of the 846 examined just three children were 
found whose teeth were in perfect condition, 
one a colored boy eleven years old, another a 
Slavish girl of ten years who had been in 
America about six months, and one, an Ameri- 
can-born child, aged twelve, who was of Russian 
parentage. One little lad was found to have 
three abscesses, two well developed and the 
third forming. (Would it be surprising if he 
annoyed his classmates or refused to conform 
to the simplest regulations of the school?) 

Such a condition was naturally startling, 
and we were very much gratified to have the 
board of education authorize a more specific 
examination the next year. 

Dr. L. A. Krejci conducted this examination 
at our school. Two classes of about forty 
children each were examined in a day. Dupli- 
cate charts were made, one being kept by the 
dentist and one sent to the parents of the 


child. When the examinations of the schools 
were completed, Dr. Ebersole requested that 
a special class be formed for observation and 
study. The purpose was to ascertain what 
effect, if any, would be produced on the child 
physically, mentally, and morally by attention 
to the proper use and care of the oral cavity. 


For four years preceding the beginning of 
the dental work, we had at Marion School the 
volunteer services of a skilful and exceptionally 
well-equiped physician, who conducted the 
medical inspection of our children. His almost 
daily attention, aided somewhat by special 
emphasis on physical culture and daily rhyth- 
mic drill, had completely transformed the chil- 
dren in our school district. Though living 
under the same social, economic, and industrial 
conditions as pupils in adjacent school districts, 
the children at Marion School invariably im- 
pressed visitors, official or otherwise, as being 
children of a more fortunate type physically, 
morally, and mentally. Knowing, therefore, 
what medical inspection had done for us, I took 
precautions before beginning the dental ex- 
periment to so safeguard our medical record 
that no credit would go to the oral hygiene 
work that rightfully belonged to general medi- 


cal efforts. I was willing to grasp and aid 
any additional movement for the betterment of 
the growing child, but each resource must stand 
on its own merits. While I was by no means 
antagonistic to the movement for oral hygiene, 
I was very jealous of the records that we had 
previously made in improving our children. 


In order, therefore, that the Oral Hygiene 
Committee could not take credit for work done 
by others, I took the pains to secure written 
statements of conditions from reliable people 
who had seen the work. I have not needed to 
use them, and in fact have become more con- 
vinced than those who were trying to convince 

If this was to be a scientific experiment, it 
must be conducted with the utmost accuracy 
possible. All of you who have dealt with 
children know that they can be made to perform 
phenomenal feats if skilfully handled. It was 
our firm determination to keep in every way 
possible the efforts and environment of these 
children absolutely normal, and have as little 
attention as possible directed to the children 
and to their work, and no undue pressure 
brought to bear. 

Our sessions were held after school, when 
all other children had been dismissed for home. 


Only what was absolutely necessary was ever 
said in the building concerning the work and 
the children. So little attention did they 
attract for the first six months that many of 
the teachers in the building did not know who 
of their own pupils were in the class. Of 
course the distribution of five-dollar gold pieces 
at Christmas time, of which I will speak later, 
made any further quietude an impossibility. 
Fortunately by that time our work was prac- 
tically ended, and publicity could do no harm. 
Then, again, we conducted the psychological 
tests with as great a degree of uniformity and 
accuracy as was possible. In fact we can 
publicly vouch that nothing was in any way 
done that would influence a favorable result. 
What we have attained have been as nearly 
normal results as it is possible for human effort 
to attain, and are due, I believe, wholly to oral 

With a mental attitude as described we or- 
ganized our dental squad. With the assistance 
of Dr. Krejci, the examining dentist, the charts 
for all the children, from the fourth to the 
seventh grade inclusive, were looked over. We 
did not consider any eighth-grade children, be- 
cause they were soon to leave us for high school, 
nor any below the fourth grade, as their limited 
abilities would make the results of the psycho- 
logical tests practically valueless to us. 

Out of the entire number of charts forty 


were selected that showed the greatest number 
of defects. We made no other condition in 
the selection. It developed that among the 
forty whose charts showed the worst condition 
were some of our best pupils and some of the 
opposite element ; in fact it typically represented 
the school. This we deemed a most happy 

Conditions for the Marion School Dental 
Squad. — The forty children were assembled 
after school on May 18, 1910. Dr. Ebersolc 
explained what was required of them: (1) 
They were to have their teeth put into perfect 
condition at no expense to themselves. (£) 
They were to brush their teeth carefully three 
times a day. (3) They were to masticate their 
food properly, not using liquid with solid food. 
(4) They were to attend any and every meet- 
ing of the class called, and take from time 
to time psychological tests, and were to con- 
form to regulations laid down by Mrs. Van 
Gastle, who was to act in the capacity of 
supervising nurse. As a reward for this co- 
operation each child who faithfully lived up to 
the requirements was to receive a five-dollar 
gold piece on the Friday preceding Christmas. 
To make the reward more tangible and real, 
Dr. Ebersole gave the gold pieces to me in 
the presence of the children, and I held them 
in trust for them. It was necessary that some- 


thing attractive be offered to have their faithful 
co-operation. It could hardly be expected that 
the juvenile mind would appreciate the value of 
experimental proofs of dental prophylaxis, and 
from a purely altruistic motive conform to a 
series of new and taxing regulations, hence the 
wisdom of the reward in gold. At this time, 
also, each child was given a tooth-brush, a 
bottle of tooth-powder, and a plain drinking 
glass. Dr. Ebersole thoroughly explained the 
process of brushing the teeth, which to some 
of the children was something entirely new. 
Immdiately five withdrew because they would 
not assume the burden. Of those who remained, 
seven were in the seventh grade, thirteen in the 
sixth, nine in the fifth, six in the fourth grades. 
Later, at different times, three were dropped 
from the class because of failure to attend the 
tests, and five were dropped beause they did 
not keep their teeth clean and live up to the 
rules generally, leaving twenty-seven who re- 
mained faithful to the end. 

Psychological Tests. — There were a set of 
six psychological tests prepared by Dr. Wallin, 
the psychological expert. The tests were 
planned to ascertain standards in memory, 
accuracy of perception, rapidity and accuracy 
of thought, and spontaneity of association and 

Six tests were given, two before the work 


was begun on the children's teeth, two while 
the work was being done, and two a sufficient 
length of time after the mouth had been put 
in perfect condition. 

Lessons in Mastication and Insalivation. — 
Two special tests were given in the interim 
merely to illustrate to some interested parties 
what was being done. In June, 1910, about 
four weeks after the beginning of the work, 
a practical lesson in mastication and insaliva- 
tion was given by Mrs. Van Gastle, the nurse. 
Puffed wheat and cream were served the chil- 
dren, and they partook of the food, chewed and 
swallowed according to directions. 

At this time the process and necessity of 
properly chewing the food were carefully ex- 
plained, and all questions asked by the children 
were carefully and minutely answered. This 
started them intelligently in that phase of the 

Lessons in the Use of the Tooth-brush. — 
In September, 1910, the children were as- 
sembled and tested as to their ability to brush 
their teeth. They showed a vast improvement 
over what they had been able to do in the 

Test Dinner. — They were then invited to a 

three-course dinner, prepared by the school and 

served in the building. The meal consisted of 

roast beef, potatoes, tomato salad, wafers, 



grape jelly, and dessert. After they had 
finished eating, each child was served a glass 
of water. 

At that meeting one of the boys said that he 
had been in the habit of drinking six and eight 
cups of coffee a day, but since beginning to 
chew as he had been taught, he had lost the 
taste for coffee, and now sometimes did not 
drink one cup in two or three days. Most of 
the children took the trouble to explain how 
much better they liked the new way of eating. 
Many interesting and varied accounts were re- 
lated which showed how thoroughly they had 
taken up and were pursuing the prescribed 
course of action. 

Operative Dental Work. — In the meantime 
Drs. Loupe and Moffett were treating the teeth 
of each child. Regular appointments were made 
and the teeth of each child put in good con- 
dition. Dr. Chas. K. Teter performed what 
extractions were needed, and Dr. Varney 
Barnes did some work in orthodontia. 


So much for the work done ; now for results. 
As has been mentioned before, selecting only 
according to the record on the charts gave us 
children of various types. We had some who 
were well behaved, earnest, and bright children, 


and we had some of the most disobedient, reck- 
less, and troublesome ones. The class, as it 
first presented itself, notwithstanding all that 
had previously been done for them, was not 
prepossessing. One of the brightest and nicest 
girls in the class suffered very frequently from 
sick headache. Most of them had sallow, muddy 
complexions, and three of them were on the 
point of being taken into juvenile court for 
truancy. One little boy was a candidate for 
the " boys' school " because of incorrigibility. 
He was a nuisance to the school-room and a 
terror in the school-yard. The others were 
between the two extremes. 


Each case was closely watched and each, 
as the work went on, showed marked improve- 
ment. The little girl subject to sick headaches 
not only was entirely cured, but her mother, 
who followed the directions laid down for the 
little daughter, found relief from the same 
trouble. The complexions cleared, a spirit of 
self-respect was manifest ; truancy, indifference, 
and incorrigibility in these children disappeared. 

In their mental tests they have made a very 
considerable gain, 99.8 per cent., which comes 
very close to doubling their ability. 

The children who needed the improvement 


most were the ones who made the greatest 
gains. This gain of 99.8 per cent, was shown, 
as we have said, in the psychological tests. The 
tests were given one in May and one ill June 
of 1910, the next one in August, then one in 
September. The last two were given on the 
4th and 17th of May, 1911. The longest time 
spent on one phase of the work during a test 
was less than three minutes, therefore the 
pedagogical principle of repetition could not 
be effective because of the lapse of time between 
each apperception. The mental picture was 
wholly effaced before the next test was given. 

The increase in ability to do the work of 
the psychological tests is due to increase of 
power in the child rather than to accumulated 
knowledge — a distinction that is of great im- 
portance to the educator. Such results ob- 
tained in the class-room distinguish the true 
educator from the drill-master. 

The children's gain in health, self-respect, and 
knowledge of higher and better living cannot 
be marked in " per cent." But who will say 
that it is not equally if not more valuable? 
And the lesson in perseverance and continuity 
of purpose which they have had, while not 
adding anything to the dental experiment, can 
be placed in the column of assets. 

Speaking of their perseverance, we would all 
say that the anticipated reward of five dollars 


in gold was an incentive to them. But the fact 
is that the five dollars was given at the end of 
seven months' work, and during the remaining 
seven months, or up to the present time, each 
and every child has been equally persevering, 
if not more so, and that with no reward in 
sight except what was known to be the real 
benefit that comes to them by faithful atten- 
tion to oral hygiene. 

Just before the close of school last May I 
asked the children to write me a letter telling 
me what they thought of this experience. The 
whole theme of their letters seemed to be grati- 
tude for what was done for them. We should 
need no stronger proof of the efficacy of the 
work than the affidavits of the children 

One of our school officials, after witnessing 
one of the tests and hearing some of the testi- 
monials, very aptly remarked that in this day 
and age we might revise the expression, " Out 
of the overflowing heart the mouth speaketh," 
and say instead, " Out of the sanitary mouth 
the overflowing heart speaketh." 


We will now give some specific data concern- 
ing the different children : Sol Katzel, Frank 
Silverstein, Jacob Bernstein, Joe Todd, Lillian 


Gottfried, and Helen Wright did last year in 
"twenty-four weeks the same work, regularly 
done in thirty-eight weeks, and were graduated 
for high sehool in February instead of in June. 

Frank Silverstein was quarantined on account 
of scarlet fever in his home. He helped nurse 
the younger children, and every one of the six 
children in the family contracted the disease 
except himself. The attending physician 
attributed his immunity to his healthy physical 

Helen Wright was weak and nervous, and 
subject to frequent headaches. Not only has 
she grown robust, but her headaches have 

Sam Katzel in May, 1910, was in the sixth 
grade. In May, 1911, one year later, he was 
graduated from the eighth grade, having ac- 
complished two entire grades in one year. He 
had failed through indifference the year before. 

Ben Dimenstein at our district athletic meet 
this year won first place in the lightweight 
dash and first place in standing broad jump, 
securing almost two-thirds of all the points 
won by the school. Last year, although com- 
peting, he did not bring us one point : he 
says that his success was due to oral hygiene. 

Becky Goldstein has had, I believe, the hard- 
est struggle in the class. Her teeth were very 
irregular, the worst case of malocclusion I have 
17 257 


seen. During the winter her mother met with 
an accident and was taken to the hospital for 
an operation, leaving in Becky's care a baby 
two weeks old. This baby was the sixteenth in 
the family, and Becky the eldest daughter. 
For two months Becky, with the help of a 
younger sister and with the advice and help of 
some women of the neighborhood, cared for the 
baby, regulated the household, and came to 
school occasionally one or one-half day when 
she found some neighbor who would take the 
baby for a time. By so doing she kept in 
touch with the work at school, and was pro- 
moted with her class in June. But the most 
remarkable fact is that during that time, 
though she had not one unbroken night's rest 
on account of her anxiety for the baby, she 
retained her vigor and strength through it all. 

Rose Lieberman, Lillie Semlakowsky, and 
Lillie Cohen have the prettiest sets of teeth, and 
made a most marked improvement in com- 
plexion. Their improvement may be said to 
be aesthetic. 

Annie Pankuch had severe kidney trouble, 
and was a fragile, delicate, nervous child. In 
every respect she was greatly improved, and is 
sturdy and well to-day. 

Rachel Somers led her class in the last 

Gussie Hammerschlag, Beatrice Kramer, 


Bertha Semlakowsky, Sarah Macklin, Frieda 
Goldman, Sclnia Perlick, and Helen Cohen have 
shown improvement in scholarship, behavior, 
health, and appearance. 

Issie Grey's father says that since Issie has 
entered the dental class he has improved so 
that he would not give him now for all his 
other children put together, and we have some 
very nice children from the Grey family. 

Hannah Cohen has not had the full quota 
of mental endowments. She has been in 
America about three years, has had many diffi- 
culties to overcome, and made a gain of 444.82 
per cent., besides improving greatly physically. 

Ida Goldman has been the most timid child 
in the class. Her fear of the dentist was such 
that at first I remained with her, and held 
her hands while the dentist worked. She re- 
sponded less readily, though she made a gain 
of 101.83 per cent. 

Harry Freeman and Abe Meyer have been 
good, faithful, steady workers and have made 
gains, besides brightening up and showing 
physical growth. 

The last and banner pupil is Morris Krause. 
Morris had ideas peculiarly his own as to what 
a boy's duties and privileges were. Those ideas 
were so much at variance w T ith the conventional 
standards that difficulties arose, seemingly in- 
surmountable at times. Since working with the 


class he has been manly, tractable, and does 
not even seem to have the temptations that 
repeatedly assailed him and were almost the 
means of his down-fall. The result obtained 
for Morris alone was worth all our efforts. 


I am thoroughly convinced of the efficiency 
of oral hygiene. I believe that if each child 
be taught to intelligently keep thoroughly clean 
and healthy the gateway to his system, the 
mouth, we will have a healthier, more self-re- 
specting, and all-around better class of citizens 
for the next generation. What has been done 
for these twenty-seven children may be done 
for every child. If we are called upon to 
educate children living in crowded city quarters, 
breathing varieties of harmful gases instead of 
pure air, eating food adulterated or sold from 
shops that display their goods uncovered and 
exposed to the germs that are scattered by that 
portion of our six hundred thousand population 
that may chance to pass that way; if, as a 
distinguished physician says, the majority of 
cases of pulmonary tuberculosis are contracted 
through the alimentary canal — then we must 
fortify our children by every means in our 
power; — and one of the most effective guns on 
our fortification is a practical working knowl- 
edge and training in oral hygiene." 


The writer feels that this report is a re- 
markable showing, and that it should 
challenge the attention and interest of 
every one in any way connected with the 
subjects of primary or secondary educa- 
tion, public health, or good citizenship. 

In what way can the thought and 
energies of our school boards, public 
health boards, managers of philanthropic 
institutions, the State and the public gen- 
erally be better spent than in removing 
these dangers to the health, physically, 
mentally, and morally, of our school- 

The results of the experiments above 
quoted prove beyond the shadow of a 
doubt that if oral hygiene were taught in 
our public schools, and the teeth of the 
children properly cared for, at public ex- 
pense when necessary, but insisted upon 
when parents were able to bear the cost, 
great advantage would accrue to the 

This advantage would be of the greatest 
moment economically, as it would mater- 
ially lessen the expense of education, re- 
duce the number of the sick and the 
mentally incompetent that become a pub- 



lie charge, also lessen the number of 
criminals and insane persons that have to 
be taken care of by the State, and greatly 
assist in elevating the physical, mental, 
and moral stamina of the nation. " The 
health of the people is the supreme law/' 



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